EM Fellowship

[LeroyJenkinsMD]

This question is for anyone who has completed an EM fellowship. Have you been able to get any jobs that you couldn’t get without the fellowship?

My program is weak in EM, I have an interest, and I don’t think securing an additional residency in EM would be possible. With an additional year of EM rotations, ICU, etc during fellowship plus electives during residency, I think I would have very similar training on paper as current EM residency folks. At the very least I would certainly be more comfortable working jobs I’ve already been offered as a resident.

My goal is to maintain my own clinic 4 days per week and then moonlight in small rural ERs on the weekends with the highest bidder when I’m not feeling too burned out. The higher level trauma centers do not appeal to me because you are worked like a dog and consultants run the show. I also want to maintain “my patients” because I believe there is value in having a loyal patient base as opposed to being an administrative slave. Moonlighting at various outlying facilities would also help grow my clinic.

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[Lexdiamondz]

This question is for anyone who has completed an EM fellowship. Have you been able to get any jobs that you couldn’t get without the fellowship?

My program is weak in EM, I have an interest, and I don’t think securing an additional residency in EM would be possible. With an additional year of EM rotations, ICU, etc during fellowship plus electives during residency, I think I would have very similar training on paper as current EM residency folks. At the very least I would certainly be more comfortable working jobs I’ve already been offered as a resident.

My goal is to maintain my own clinic 4 days per week and then moonlight in small rural ERs on the weekends with the highest bidder when I’m not feeling too burned out. The higher level trauma centers do not appeal to me because you are worked like a dog and consultants run the show. I also want to maintain “my patients” because I believe there is value in having a loyal patient base as opposed to being an administrative slave. Moonlighting at various outlying facilities would also help grow my clinic.

So you turn your nose up at Level 1 trauma centres and yet you want to do my job with ¼ of my training in a rural area where you have zero backup?


You don't seem to know much about EM, Trauma or FM for that matter. A year of fellowship will make you more comfortable in the ED, but it certainly wouldn't make you similar to an EM trained physician - either on paper or in practice. Train for the job you want.

 

[LeroyJenkinsMD]

So you turn your nose up at Level 1 trauma centres and yet you want to do my job with ¼ of my training in a rural area where you have zero backup?

You don't seem to know much about EM, Trauma or FM for that matter. A year of fellowship will make you more comfortable in the ED, but it certainly wouldn't make you similar to an EM trained physician - either on paper or in practice. Train for the job you want.

I’m sorry. I didn’t mean to offend anyone. That’s why I posted this in the FM forum. The purpose of this post was not to debate training. I think three years of family medicine (clinic, inpatient, codes, ICU, surgical OB, EM, urgent care, nursing home, inpatient/outpatient peds, anesthesia) plus one year of emergency medicine is very, very good training and I don’t feel the need to defend it.

My original question stands if anyone has any feedback. Trying to decide if the fellowship has any marketable value. Looks like they are increasing in number and becoming popular. Most are also taught at big centers by boarded ABEM physicians.

 

[CCM-MD]

Looks like the CCM fellowship plans didn’t pan out.

There are still many EDs in less diserable areas that are staffed by non-EM residency trained physicians. I get emails about these jobs from time to time. Most of these jobs ask for “ER experience” - so if you have experience working in the ED, I don’t think a fellowship would add much marketability - these employers are often desperate to hire ANYONE. I think a fellowship might be helpful in adding at least some EM skills that would prevent you from hurting patients - like airway management for example - if you are a new grad who doesn’t have this experience. If you are a fresh grad without “ER experience” perhaps it would add to your marketability for employers who are still willing to hire non-EM residency trained physicians.

I think if you are interested in embarking on this path, an EM fellowship is probably better than no EM training at all.

 

[LeroyJenkinsMD]

Looks like the CCM fellowship plans didn’t pan out.

There are still many EDs in less diserable areas that are staffed by non-EM residency trained physicians. I get emails about these jobs from time to time. Most of these jobs ask for “ER experience” - so if you have experience working in the ED, I don’t think a fellowship would add much marketability - these employers are often desperate to hire ANYONE. I think a fellowship might be helpful in adding at least some EM skills that would prevent you from hurting patients - like airway management for example - if you are a new grad who doesn’t have this experience. If you are a fresh grad without “ER experience” perhaps it would add to your marketability for employers who are still willing to hire non-EM residency trained physicians.

I think if you are interested in embarking on this path, an EM fellowship is probably better than no EM training at all.

Again, this question is for anyone who has completed an EM fellowship. Let’s try to keep this thread useful. Annoying personal attacks implying that I am a failure will be ignored.

Also, any family physicians care to weigh in?

 

[Sardonix]

You had to know this was gonna piss people off.

Sounds like a self fulfilling prophecy type thing, just because you say it out loud doesn't make it true.

I know you could care less about my opinion, I'm just an M3, but I bet you'd get into more EDs if you showed some humility.

Yeah there are like x50 threads in the EM forum starting out with similar statements and they all end with the verbal equivalent of being beaten with a phonebook/chargemaster.

 

[LeroyJenkinsMD]

This question is for anyone who has completed an EM fellowship. Have you been able to get any jobs that you couldn’t get without the fellowship?

 

[MedicineZ0Z]

So you turn your nose up at Level 1 trauma centres and yet you want to do my job with ¼ of my training in a rural area where you have zero backup?


You don't seem to know much about EM, Trauma or FM for that matter. A year of fellowship will make you more comfortable in the ED, but it certainly wouldn't make you similar to an EM trained physician - either on paper or in practice. Train for the job you want.

Rural jobs exist because they aren't filled. Someone needs to see those patients.
For the most part, you need to know how to get an airway & a line if needed. Stabilize and transfer. If you can do more, it's a bonus.

90% of what's coming in should be fully within an FM's scope anyway...

 

[Lexdiamondz]

Rural jobs exist because they aren't filled. Someone needs to see those patients.
For the most part, you need to know how to get an airway & a line if needed. Stabilize and transfer. If you can do more, it's a bonus.

90% of what's coming in should be fully within an FM's scope anyway...

...and the 10-20% that isn't is what actually matters.

Getting an airway or a line isn't always easy - the learning curve for intubation doesn't start to flatten until you're well past >50 tubes, and most anaesthesiologists and EM attendings would tell you that you really learn the most in your first 100-150 tubes - especially unstable ones. The average FM resident doesn't graduate with all that many intubations, chest tubes, central lines, and doesn't do enough resuscitation and critical care to actually be comfortable managing these types of patients with zero backup.

EM exists as a field because the training in FM, IM and GS weren't enough to cover everything that comes through the front door. Sure, there are FM and IM trained docs who practice in EDs but for many reasons it isn't the optimal setup by a long stretch.

I’m sorry. I didn’t mean to offend anyone. That’s why I posted this in the FM forum. The purpose of this post was not to debate training. I think three years of family medicine (clinic, inpatient, codes, ICU, surgical OB, EM, urgent care, nursing home, inpatient/outpatient peds, anesthesia) plus one year of emergency medicine is very, very good training and I don’t feel the need to defend it.

My original question stands if anyone has any feedback. Trying to decide if the fellowship has any marketable value. Looks like they are increasing in number and becoming popular. Most are also taught at big centers by boarded ABEM physicians.

You just said your programme is weak in EM and now you're saying you can make up for 3 years of deficient EM with a one year fellowship? you aren't making any sense.

 

[MedicineZ0Z]

...and the 10-20% that isn't is what actually matters.

Getting an airway or a line isn't always easy - the learning curve for intubation doesn't start to flatten until you're well past >50 tubes, and most anaesthesiologists and EM attendings would tell you that you really learn the most in your first 100-150 tubes - especially unstable ones. The average FM resident doesn't graduate with all that many intubations, chest tubes, central lines, and doesn't do enough resuscitation and critical care to actually be comfortable managing these types of patients with zero backup.

EM exists as a field because the training in FM, IM and GS weren't enough to cover everything that comes through the front door. Sure, there are FM and IM trained docs who practice in EDs but for many reasons it isn't the optimal setup by a long stretch.

Well aware it isn't easy. But over the course of 3 years, you have enough elective time + time on the floor/icu to do tubes/lines. If you're at an unopposed program, there's no reason you shouldn't hit that many intubations if you're also spending time in the OR intubating.
Rare procedures you'd have to learn from courses which is essentially how the ED residents learn them too.

 

[Lexdiamondz]

Well aware it isn't easy. But over the course of 3 years, you have enough elective time + time on the floor/icu to do tubes/lines. If you're at an unopposed program, there's no reason you shouldn't hit that many intubations if you're also spending time in the OR intubating.
Rare procedures you'd have to learn from courses which is essentially how the ED residents learn them too.

Please explain to me how you're supposed to get >100 intubations in a 3 year residency that is >50% outpatient...

As for rare procedures, the only rare procedures the ACGME allows us to do in sim labs are pericardiocentesis, cardiac pacing, and cricothyrotomy. Everything else must be at least 70% on live patients.

 

[MedicineZ0Z]

Please explain to me how you're supposed to get >100 intubations in a 3 year residency that is >50% outpatient...

As for rare procedures, the only rare procedures the ACGME allows us to do in sim labs are pericardiocentesis, cardiac pacing, and cricothyrotomy. Everything else must be at least 70% on live patients.

Some FM residencies modify your schedule to hit your goals. So on top of an anesthesia month where you do 5 or so daily, you can go to the OR in the mornings on certain months and so more. Then there's any floor/unit tubes. So it is possible. Just not so much if it's not an unopposed program.
And yeah that's what I was getting at. The other stuff isn't emergent and can wait the transfer time.

 

[Lexdiamondz]

Some FM residencies modify your schedule to hit your goals. So on top of an anesthesia month where you do 5 or so daily, you can go to the OR in the mornings on certain months and so more. Then there's any floor/unit tubes. So it is possible. Just not so much if it's not an unopposed program.
And yeah that's what I was getting at. The other stuff isn't emergent and can wait the transfer time.

Most FM curricula don't include anaesthesia, the vast majority do < 3 mos of critical care (and most medical crit care fellows don't even graduate with 100 tubes just for your frame of reference) and less than 12 months of inpatient medicine. So again, I reallyyyyyy don't know where you're getting these numbers from.

Unless you are talking about programs like Ventura or JPS (and they have an optional critical care track that's an extra year) the type of program you're describing is far and away the exception, not the rule.

 

[MedicineZ0Z]

Most FM curricula don't include anaesthesia, the vast majority do < 3 mos of critical care (and most medical crit care fellows don't even graduate with 100 tubes just for your frame of reference) and less than 12 months of inpatient medicine. So again, I reallyyyyyy don't know where you're getting these numbers from.

Unless you are talking about programs like Ventura or JPS (and they have an optional critical care track that's an extra year) the type of program you're describing is far and away the exception, not the rule.

You missed my point. I was saying if one utilizes their elective time right and uses any longitudinal options - they can hit those numbers. Some FM programs modify your schedule (as I mentioned) to have you hit your goals.

 

[LeroyJenkinsMD]

When I said my program is weak in emergency medicine, I meant there aren’t that many dedicated EM only months unless you use elective time. Fortunately we are all smart people and realize that pathology seen by FM and EM physicians on the daily is not all mutually exclusive. 90% of EM is outpatient family medicine clinic at 3 AM. A good portion is also respiratory distress, stroke, ACS. We see and manage these conditions as they present, acutely, on a daily basis, on the general medicine and ICU floors as the primary attending.

We also get training in surgical obstetrics. I am trained to do c-sections. You don’t see me shouting emergency physicians are unqualified to work in rural ERs simply because I will be able to save more babies than them if there is an MVA in front of the hospital.

Because emergency medicine is not a vacuum of unique pathology, you can actually train in other settings and gain helpful knowledge. This is why emergency medicine residency is not 36 months of EM. The FM curriculum is the same way.

Now, hands down. EM is going to be better at trauma. Hence an EM fellowship for FM to make up deficits. But do not pretend like the vast majority of family medicine training is irrelevant, and do not pretend like you don’t have surgeons in the room with you during a trauma, mass casualty event, etc.

There is a respectful way to appreciate each others strengths without getting defensive.

 

[MedicineZ0Z]

When I said my program is weak in emergency medicine, I meant there aren’t that many dedicated EM only months unless you use elective time. Fortunately we are all smart people and realize that pathology seen by FM and EM physicians on the daily is not all mutually exclusive. 90% of EM is outpatient family medicine clinic at 3 AM. A good portion is also respiratory distress, stroke, ACS. We see and manage these conditions as they present, acutely, on a daily basis, on the general medicine and ICU floors as the primary attending.

We also get training in surgical obstetrics. I am trained to do c-sections. You don’t see me shouting emergency physicians are unqualified to work in rural ERs simply because I will be able to save more babies than them if there is an MVA in front of the hospital.

Because emergency medicine is not a vacuum of unique pathology, you can actually train in other settings and gain helpful knowledge. This is why emergency medicine residency is not 36 months of EM. The FM curriculum is the same way.

Now, hands down. EM is going to be better at trauma. Hence an EM fellowship for FM to make up deficits. But do not pretend like the vast majority of family medicine training is irrelevant, and do not pretend like you don’t have surgeons in the room with you during a trauma, mass casualty event, etc.

There is a respectful way to appreciate each others strengths without getting defensive.

Very well said.

Of course the EM guy will be much better in a solo run rural EM job. But those rural guys are a different breed and after years of experience they equalize.

 

[LeroyJenkinsMD]

In an attempt to keep this thread relevant and helpful for any interested family medicine physicians, I will summarize my research so far.

Do an additional EM residency if you want to work in a level one trauma center where all of the trauma is coming to you and there is very high volume.

Do an EM fellowship if you want to work in a level 2 trauma center where you will likely see a lot of trauma but not as much. A fellowship will give you more confidence and also help you out compete other family physicians that are already working in these facilities.

Do neither if you went to a solid unopposed program and are simply moonlighting at places where you ATLS, ACLS, PALS, consult and ship.

The above is simply what I have found to be the current reality when talking to employers. Obviously, opinions vary.

 

[Lexdiamondz]

When I said my program is weak in emergency medicine, I meant there aren’t that many dedicated EM only months unless you use elective time. Fortunately we are all smart people and realize that pathology seen by FM and EM physicians on the daily is not all mutually exclusive. 90% of EM is outpatient family medicine clinic at 3 AM. A good portion is also respiratory distress, stroke, ACS. We see and manage these conditions as they present, acutely, on a daily basis, on the general medicine and ICU floors as the primary attending.

We also get training in surgical obstetrics. I am trained to do c-sections. You don’t see me shouting emergency physicians are unqualified to work in rural ERs simply because I will be able to save more babies than them if there is an MVA in front of the hospital.

Because emergency medicine is not a vacuum of unique pathology, you can actually train in other settings and gain helpful knowledge. This is why emergency medicine residency is not 36 months of EM. The FM curriculum is the same way.

Now, hands down. EM is going to be better at trauma. Hence an EM fellowship for FM to make up deficits. But do not pretend like the vast majority of family medicine training is irrelevant, and do not pretend like you don’t have surgeons in the room with you during a trauma, mass casualty event, etc.

There is a respectful way to appreciate each others strengths without getting defensive.

Don't give me this bull about you lot manage acute presentations on a daily basis in gen med and the ICUs when the bulk of your training is outpatient. If 90% of EM is FM outpatient clinic, why are outpatient physicians always sending patients to my ER to "rule out xyz"?

EM isn't a vacumn of unique pathology, but the pathology we see is undifferentiated and that is precisely where the difference in training matters. Nobody cares if you can run a code on the floor - if you can't pick out the sick patient in the waiting room and keep them from coding in the first place you don't get to pat yourself in the back for getting ROSC.

But hey, maybe you're the exception to the rule and can absolutely do our job better than we can. However the fact that you quite stupidly seem to thing being able to do a c-section and save the baby is a useful skill in an MVA (because fxck mom, right?) makes me think that you're woefully ignorant of what being a competent EM physician actually entails.

Very well said.

Of course the EM guy will be much better in a solo run rural EM job. But those rural guys are a different breed and after years of experience they equalize.

Except there's absolutely no way to measure that.

With that said, EM residencies, ATLS and ACLS were created because physicians of other specialties were woefully unprepared to handle emergencies in a coherent, efficient and effective way. ATLS specifically was created because rural providers had no fxcking clue what to do with trauma despite these years of experience and ended up killing an orthopaedic surgeon's entire family because of it. This isn't to say that there aren't good rural providers, but you can't assume running out into the forest and figuring **** out for several years with no guidance and no way to reflect on how effective your management is will make you a good doctor. You can stabilise and ship for years and do a shi*te job and have no idea.

 

[deleted87716]

ATLS and ACLS were created because physicians of other specialties were woefully unprepared to handle emergencies in a coherent, efficient and effective way. ATLS specifically was created because rural providers had no fxcking clue what to do with trauma despite these years of experience and ended up killing an orthopaedic surgeon's entire family because of it. This isn't to say that there aren't good rural providers, but you can't assume running out into the forest and figuring **** out for several years with no guidance and no way to reflect on how effective your management is will make you a good doctor. You can stabilise and ship for years and do a shi*te job and have no idea.

 

[LeroyJenkinsMD]

Don't give me this bull about you lot manage acute presentations on a daily basis in gen med and the ICUs when the bulk of your training is outpatient. If 90% of EM is FM outpatient clinic, why are outpatient physicians always sending patients to my ER to "rule out xyz"?

EM isn't a vacumn of unique pathology, but the pathology we see is undifferentiated and that is precisely where the difference in training matters. Nobody cares if you can run a code on the floor - if you can't pick out the sick patient in the waiting room and keep them from coding in the first place you don't get to pat yourself in the back for getting ROSC.

But hey, maybe you're the exception to the rule and can absolutely do our job better than we can. However the fact that you quite stupidly seem to thing being able to do a c-section and save the baby is a useful skill in an MVA (because fxck mom, right?) makes me think that you're woefully ignorant of what being a competent EM physician actually entails.



Except there's absolutely no way to measure that.

With that said, EM residencies, ATLS and ACLS were created because physicians of other specialties were woefully unprepared to handle emergencies in a coherent, efficient and effective way. ATLS specifically was created because rural providers had no fxcking clue what to do with trauma despite these years of experience and ended up killing an orthopaedic surgeon's entire family because of it. This isn't to say that there aren't good rural providers, but you can't assume running out into the forest and figuring **** out for several years with no guidance and no way to reflect on how effective your management is will make you a good doctor. You can stabilise and ship for years and do a shi*te job and have no idea.

My training is one half inpatient. We follow our patients through the ICU. We round in the morning and have clinic in the afternoons.

Because I don’t have a CT scanner in my clinic.

The triage nurses pick out the sick patient from the waiting room.

So.. there are indications for emergent delivery. Some level one centers have separate EDs for pregnant ladies staffed with OB hospitalists.

ATLS was created by surgeons. EM physicians take the class.

 

[MedicineZ0Z]

Except there's absolutely no way to measure that.

With that said, EM residencies, ATLS and ACLS were created because physicians of other specialties were woefully unprepared to handle emergencies in a coherent, efficient and effective way. ATLS specifically was created because rural providers had no fxcking clue what to do with trauma despite these years of experience and ended up killing an orthopaedic surgeon's entire family because of it. This isn't to say that there aren't good rural providers, but you can't assume running out into the forest and figuring **** out for several years with no guidance and no way to reflect on how effective your management is will make you a good doctor. You can stabilise and ship for years and do a shi*te job and have no idea.

I think you're making a generalization just like everyone does about typical urban ED guys.
It's the doctor's responsibility to improve themself via courses and reading and to take the right electives in residency to prep for being an attending.

 

[Lexdiamondz]

My training is one half inpatient. We follow our patients through the ICU. We round in the morning and have clinic in the afternoons.

Because I don’t have a CT scanner in my clinic.

The triage nurses pick out the sick patient from the waiting room.

So.. there are indications for emergent delivery. Some level one centers have separate EDs for pregnant ladies staffed with OB hospitalists.

ATLS was created by surgeons. EM physicians take the class.

"following a patient" =/= being an intensivist. Med students "follow patients" my friend. In your <18mos of inpatient training (most of which was probably as an intern) you likely didn't lead the resus, work them up, and you likely arent directing their care in the unit either.

Yeah there are indications for emergent delivery...and simply being in an MVA isn't one of them. But if you think 18 mos of inpatient training and being first assist on a couple of c-sections makes you a solid ER doc then I won't argue, by all means go out into the wild and sort yourself out.

 

[CCM-MD]

"A small amount of expertise or knowledge can mislead a person into thinking that they’re an expert because it is often easy to get a small amount of knowledge. They think that it’s all it takes.

They also think that those that have actual superior knowledge and experience are only marginally different than themselves."

 

[MedicineZ0Z]

"following a patient" =/= being an intensivist. Med students "follow patients" my friend. In your <18mos of inpatient training (most of which was probably as an intern) you likely didn't lead the resus, work them up, and you likely arent directing their care in the unit either.

Yeah there are indications for emergent delivery...and simply being in an MVA isn't one of them. But if you think 18 mos of inpatient training and being first assist on a couple of c-sections makes you a solid ER doc then I won't argue, by all means go out into the wild and sort yourself out.

I think you're over estimating how good most ED docs are, and even how good modern medicine is.
You're also talking down another physician but would keep your lips tight if it was an NP/PA. Let me guess, you're okay with all the hospitals in the country having their ICUs run by a nurse with some online courses/shadowing? Cause that's literally what happens at every hospital that doesn't have an IM program.
But a family doc, who has literally dozens of times more knowledge, doing some of that work? Hellnaw. Cause those midlevels are "supervised" lololol.

"A small amount of expertise or knowledge can mislead a person into thinking that they’re an expert because it is often easy to get a small amount of knowledge. They think that it’s all it takes.

They also think that those that have actual superior knowledge and experience are only marginally different than themselves."

Don't think this happens in Canada but you know American ICUs are run by nurse practitioners overnight? Not to mention half the workload as well. Think about that... a nurse can do some online courses and shadow an NP for a few weeks/months (literally). And they get hired on. And sure they have some "on the job training." And hopefully you realize family docs who have an infinitely higher starting point can have elective/additional training in ER etc.


BTW, the only "supervision" that happens with midlevels is them supervising other doctors (residents). I'm not even kidding. It's a rampant thing in so many residencies now. On paper it's the attending. In practice, it's the midlevel.

 

[Vandalia]

Let me guess, you're okay with all the hospitals in the country having their ICUs run by a nurse with some online courses/shadowing?

See the above diagram. The difference is that the midlevels are perfectly happy practicing following set guidelines. I do not have a problem with a midlevel because they do exactly what they are instructed to do. If they deviate for a second they are canned. The problem is that the non-EM physicians I have dealt with over the years think they actually know something about EM and start to freelance. There is an incredible difference between a midlevel in an ICU who is forbidden from exercising medical judgement and is required to follow set procedures, and a non-critical care physician who thinks that their training qualifies them to exercise medical judgement in an ICU. I do not have a problem with an NP in the ICU instructing a resident what the set polices are. You have to learn the rules before you can learn the exceptions.

The other issue is that if you are willing to work for an NP salary I would be glad to hire you. (Or more specifically I would have.) Any physician who is wiling to work for $90K/year (that is what we are paying) a year is more than welcome to a job in the ED.

 

[CCM-MD]

I work in the US. We used to take home call for our ICUs initially with a nocturnist (IM trained) in house. Our hospital got busy and the nocturnists wanted out of night time ICU coverage, so we switched to a night midlevel with us on call from home, and recently after a bad outcome our hospital was willing to pay so we changed to 24/7 inhouse intensivist coverage.

There is a midlevel "issue" in pretty much every specialty. I work in the US but Canada has "issues" also - not as much of an issue (yet). When I request any consult - cardiology/GI/surgery, you name it - I get an NP. For argument's sake, lets agree that most FM physicians are much more knowledgeable than the cardiology NP - no one is going to agree that its a good idea to create 1 year FM-cardiology fellowships and call them cardiologists in rural areas.

No hospital I know of has midlevels supervising residents - pretty sure that is against ACGME rules. If you've seen it, you should report it, otherwise you are doing a disservice to all of us.

All that being said, if there is an FP wanting to work in my unit at the intern/junior resident level for $85-95k a year, come on down! I HIGHLY doubt any self-respecting FP is willing to take that paycut and blindly follow the plan of care created by a more specialized physician - midlevels on the other hand are more than happy to.

 

[LeroyJenkinsMD]

Dear EM fellowship grads,

Please stop working immediately. Your training is terrible, and you’re killing everyone. Hospitals will still hire you because they don’t track data, ever. However, they will figure this whole thing out soon so please discontinue the successful expansion of your programs that anonymous people on the internet disagree with. Never mind things like outcomes, evidence, science, market forces. Just trust me, and please don’t put downward pressure on my salary.

Sincerely,
The other SDN specialty forums

 

[Lexdiamondz]

I think you're over estimating how good most ED docs are, and even how good modern medicine is.
You're also talking down another physician but would keep your lips tight if it was an NP/PA. Let me guess, you're okay with all the hospitals in the country having their ICUs run by a nurse with some online courses/shadowing? Cause that's literally what happens at every hospital that doesn't have an IM program.
But a family doc, who has literally dozens of times more knowledge, doing some of that work? Hellnaw. Cause those midlevels are "supervised" lololol.
¨

And as a med student you really don't have much perspective on what makes a good ED doc, a good FP or even how good modern medicine is. You literally have no yardstick to judge by.

I'm not talking down another physician for saying that they aren't trained to do my job. They just aren't. I read dozens of CXRs, Head CTs and extremity films a day but I'm not a radiologist. I intubate and perform conscious sedations regularly but I'm not an anaesthesiologist. I use pressors, run codes and place lines frequently but I'm not an intensivist. My field overlaps with essentially every other field in medicine, and yet I'm perfectly comfortable saying certain things are outside of my scope of practice that my training did not prepare me for.

Humility is important. How deep your fund of knowledge is is irrelevant - a physician who doesn't recognise and acknowledge their limitations is a danger to their patients and themselves dude.

 

[LeroyJenkinsMD]

And as a med student you really don't have much perspective on what makes a good ED doc, a good FP or even how good modern medicine is. You literally have no yardstick to judge by.

I'm not talking down another physician for saying that they aren't trained to do my job. They just aren't. I read dozens of CXRs, Head CTs and extremity films a day but I'm not a radiologist. I intubate and perform conscious sedations regularly but I'm not an anaesthesiologist. I use pressors, run codes and place lines frequently but I'm not an intensivist. My field overlaps with essentially every other field in medicine, and yet I'm perfectly comfortable saying certain things are outside of my scope of practice that my training did not prepare me for.

Humility is important. How deep your fund of knowledge is is irrelevant - a physician who doesn't recognise and acknowledge their limitations is a danger to their patients and themselves dude.

Let’s pretend that family physicians don’t work in emergency departments everywhere and do just fine. Let’s say there is no significant amount of overlap in training, that family doctors aren’t “kind of good at everything” too, and that family physicians created the specialty of emergency medicine because they were incompetent fools—not because ophthalmologists had no business managing MIs. I will then agree that they aren’t trained to do your job.

However, the problem is that you’re arguing that family physicians can’t be trained to do your job. The very skills you listed above are taught in fellowships and signed off on by ABEM physicians. Your willingness and need to ignore this is what is intellectually dishonest and irrational.

To suggest someone is dangerous or prideful for seeking further training is tribalistic and unhelpful for anyone trying to research the topic this thread was intended for.

 

[MedicineZ0Z]

See the above diagram. The difference is that the midlevels are perfectly happy practicing following set guidelines. I do not have a problem with a midlevel because they do exactly what they are instructed to do. If they deviate for a second they are canned. The problem is that the non-EM physicians I have dealt with over the years think they actually know something about EM and start to freelance. There is an incredible difference between a midlevel in an ICU who is forbidden from exercising medical judgement and is required to follow set procedures, and a non-critical care physician who thinks that their training qualifies them to exercise medical judgement in an ICU. I do not have a problem with an NP in the ICU instructing a resident what the set polices are. You have to learn the rules before you can learn the exceptions.

The other issue is that if you are willing to work for an NP salary I would be glad to hire you. (Or more specifically I would have.) Any physician who is wiling to work for $90K/year (that is what we are paying) a year is more than welcome to a job in the ED.

You're describing what RNs do, not what NPs do lol. They place orders. They make judgement calls when someone isn't doing well. They perform procedures unsupervised.
Maybe in your state that's the case but in the 6 I've rotated through and several others I know of - what I described is exactly what happens. They are literally no different than a physician once the doctor goes home. Will they call and ask for help when **** hits the fan? sure... but more often than not they're making the call.

I work in the US. We used to take home call for our ICUs initially with a nocturnist (IM trained) in house. Our hospital got busy and the nocturnists wanted out of night time ICU coverage, so we switched to a night midlevel with us on call from home, and recently after a bad outcome our hospital was willing to pay so we changed to 24/7 inhouse intensivist coverage.

There is a midlevel "issue" in pretty much every specialty. I work in the US but Canada has "issues" also - not as much of an issue (yet). When I request any consult - cardiology/GI/surgery, you name it - I get an NP. For argument's sake, lets agree that most FM physicians are much more knowledgeable than the cardiology NP - no one is going to agree that its a good idea to create 1 year FM-cardiology fellowships and call them cardiologists in rural areas.

No hospital I know of has midlevels supervising residents - pretty sure that is against ACGME rules. If you've seen it, you should report it, otherwise you are doing a disservice to all of us.

All that being said, if there is an FP wanting to work in my unit at the intern/junior resident level for $85-95k a year, come on down! I HIGHLY doubt any self-respecting FP is willing to take that paycut and blindly follow the plan of care created by a more specialized physician - midlevels on the other hand are more than happy to.

Supervising on paper? Of course it's the attending. But when the resident is reporting their plan to the midlevel and the midlevel is the one giving feedback and modifying it based on what THEY think, that's practical supervision.

And as a med student you really don't have much perspective on what makes a good ED doc, a good FP or even how good modern medicine is. You literally have no yardstick to judge by.

I'm not talking down another physician for saying that they aren't trained to do my job. They just aren't. I read dozens of CXRs, Head CTs and extremity films a day but I'm not a radiologist. I intubate and perform conscious sedations regularly but I'm not an anaesthesiologist. I use pressors, run codes and place lines frequently but I'm not an intensivist. My field overlaps with essentially every other field in medicine, and yet I'm perfectly comfortable saying certain things are outside of my scope of practice that my training did not prepare me for.

Humility is important. How deep your fund of knowledge is is irrelevant - a physician who doesn't recognise and acknowledge their limitations is a danger to their patients and themselves dude.

All those things you described are skills that can be obtained by a full generalist which is what an FM is.

 

[LeroyJenkinsMD]

I think every other specialty could do FM just as good if not better than you Triggered? Ya bc that's artarded

Probably not the case, but I’d be willing to hear an argument and if convincing potentially agree with you. There’s nothing mystical about working through a differential and looking up a plan. My specialty is, gasp, certainly something other people could learn how to do.

 

[LeroyJenkinsMD]

I suspect welcoming mid levels into the ED with open arms is because

1) EM physicians don’t have a choice
2) Mid levels are profitable
3) Mid levels are less threatening to job security because the lack of medical school/residency argument applies

However the above is changing as emergency medicine becomes entirely corporation run. For medicine in general, we are in a race to the bottom, not the top. This is why EM fellowship with a private practice option to fall back on is a wise option. I encourage medical students to research this in more detail. Very easy to make several thousand dollars in the ED every weekend and slowly grow a cash only direct primary care, etc.

 

[CCM-MD]

I have never seen a resident "reporting their plan to a midlevel and a midlevel giving feedback". What kind of hospital are you training at? Sounds like someone needs to send an email to the ACGME. Perhaps you should share the name of the program to warn prospective residents.

Below is from the ACGME IM program requirements - maybe FM is different and allows this sort of thing - which is a problem.

Below is the question that is on the annual ACGME survey for ALL residency and fellowship programs. They take this pretty seriously.

 

[Lexdiamondz]

Let’s pretend that family physicians don’t work in emergency departments everywhere and do just fine. Let’s say there is no significant amount of overlap in training, that family doctors aren’t “kind of good at everything” too, and that family physicians created the specialty of emergency medicine because they were incompetent fools—not because ophthalmologists had no business managing MIs. I will then agree that they aren’t trained to do your job.

However, the problem is that you’re arguing that family physicians can’t be trained to do your job. The very skills you listed above are taught in fellowships and signed off on by ABEM physicians. Your willingness and need to ignore this is what is intellectually dishonest and irrational.

To suggest someone is dangerous or prideful for seeking further training is tribalistic and unhelpful for anyone trying to research the topic this thread was intended for.

Do you realise that you're more or less using the same arguments that NPs having been using to go after your jobs? Seriously.

You're describing what RNs do, not what NPs do lol. They place orders. They make judgement calls when someone isn't doing well. They perform procedures unsupervised.
Maybe in your state that's the case but in the 6 I've rotated through and several others I know of - what I described is exactly what happens. They are literally no different than a physician once the doctor goes home. Will they call and ask for help when **** hits the fan? sure... but more often than not they're making the call.


Supervising on paper? Of course it's the attending. But when the resident is reporting their plan to the midlevel and the midlevel is the one giving feedback and modifying it based on what THEY think, that's practical supervision.

All those things you described are skills that can be obtained by a full generalist which is what an FM is.

I'm quite curious what farce of an institution you are training at. I've never seen or heard of this in my life.

 

[LeroyJenkinsMD]

Do you realise that you're more or less using the same arguments that NPs having been using to go after your jobs? Seriously.



I'm quite curious what farce of an institution you are training at. I've never seen or heard of this in my life.

I was going to say the same thing about you. The difference is I’m not arguing that I’m an irreplaceable snowflake.

 

[MedicineZ0Z]

Do you realise that you're more or less using the same arguments that NPs having been using to go after your jobs? Seriously.



I'm quite curious what farce of an institution you are training at. I've never seen or heard of this in my life.

You're now putting midlevels and doctors on the same platform. False equivalency at its finest.
And I think you greatly misunderstood what I was saying.

 

[TableMD]

So yea I am an FP and I did a one year fellowship in sports med, and I am happy with the additional training. There is nothing wrong with wanting to learn more and add additional skills in my opinion.

I had a classmate think about the ED fellowship vs doing a second legit ED residency and ultimately went into outpatient private practice and hasn't looked back. Her sense was that the fellowship was untrustworthy for her goals and looked at that only briefly.

I’d take a hard look at what these ED docs are trying to tell you. Owning an ED and all that can happen there is a unique skill, and you ought to really consider doing a second residency if its something you really want. It would only be 2 additional years and you would get the right training for the job. Or, if you want my advice, work as an FP and maybe moonlight at an urgent care? Good luck with whatever you do.

 

[MedicineZ0Z]

You just said MLs modify residents a/p based on what they think, wtf are u talking about

That *does* happen on subspecialty rotations when there's no residents/fellows in that subspecialty.

 

[CCM-MD]

So let me get this straight. At this supposed institution you are training at - residents present and get feedback from midlevels in a subspecialty that has no residents. What?

 

[deleted480308]

I'm quite curious what farce of an institution you are training at. I've never seen or heard of this in my life.

Yeah, I certainly don't present to a midlevel. And when I was a student on an outpatient rotation, if the docs had the afternoon off and the midlevels were the only ones seeing patients the residents would walk out.

 

[MedicineZ0Z]

So let me get this straight. At this supposed institution you are training at - residents present and get feedback from midlevels in a subspecialty that has no residents. What?

You don't understand what I'm saying. When you're off service/on a specialty rotation with no residents, you work with X team which involves the attending(s) and his/her 1-3+ midlevels. But "working with" often turns into the midlevel being above you in the practical sense. You can look at it from any angle, whether it's autonomy or whatever - but that np/pa is above you on that team. And this is something I have noticed at different hospitals in different states and this thread is the first time I've had someone go "what!?"

 

[cbrons]

...and the 10-20% that isn't is what actually matters.

Getting an airway or a line isn't always easy - the learning curve for intubation doesn't start to flatten until you're well past >50 tubes, and most anaesthesiologists and EM attendings would tell you that you really learn the most in your first 100-150 tubes (EM attendings) or first 10,000 tubes (anesthesiology attendings who 1000x more of them than ED attendings) - especially unstable ones. The average FM resident doesn't graduate with all that many intubations, chest tubes, central lines, and doesn't do enough resuscitation and critical care to actually be comfortable managing these types of patients with zero backup.

EM exists as a field because the training in FM, IM and GS weren't enough to cover everything that comes through the front door. Sure, there are FM and IM trained docs who practice in EDs but for many reasons it isn't the optimal setup by a long stretch.




You just said your programme is weak in EM and now you're saying you can make up for 3 years of deficient EM with a one year fellowship? you aren't making any sense.

FTFY

 

[CCM-MD]

You don't understand what I'm saying. When you're off service/on a specialty rotation with no residents, you work with X team which involves the attending(s) and his/her 1-3+ midlevels. But "working with" often turns into the midlevel being above you in the practical sense. You can look at it from any angle, whether it's autonomy or whatever - but that np/pa is above you on that team. And this is something I have noticed at different hospitals in different states and this thread is the first time I've had someone go "what!?"

Looks like you're a Caribbean/DO student and encountered this while rotating in some "not-so-academic" settings perhaps with attending physicians who may/may not have a vested interest in your education. That's something between your school and its students - looks like it is providing "subpar" clinical education if you're essentially being precepted by midlevels.

With regards to residencies - I have never seen or heard of residents in any ACGME accredited program "reporting their plan to a midlevel and a midlevel giving feedback". As I mentioned previously, this is probably not in line with the ACGME program requirements for IM - I can't speak for other specialties.

 

[smq123]

Ok, I think this topic has been beaten to death.

If you want to do an EM fellowship, go ahead - clearly, the arguments presented have not swayed anyone. But be aware of the limitations of this training pathway, for the sake of any future patients.

Closing.