EM fellowships for FM docs...

[deleted480308]

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I'm hoping to become a rural primary care doc but I also know that EM medicine opens a lot of doors for practice locations. I've noticed that there are now dual FM/EM residency programs and something that I just saw where there are 1yr fellowships in EM for FM docs.

Can someone shed some light on the difference between those two paths and if you personally see any benefit/nonbenefit to the two? Can both be EM boarded? Do you need even need EM credentials to work an EM in a small town?

 

[diphenyl]

I'm hoping to become a rural primary care doc but I also know that EM medicine opens a lot of doors for practice locations. I've noticed that there are now dual FM/EM residency programs and something that I just saw where there are 1yr fellowships in EM for FM docs.

Can someone shed some light on the difference between those two paths and if you personally see any benefit/nonbenefit to the two? Can both be EM boarded? Do you need even need EM credentials to work an EM in a small town?

A dual residency leads to board eligibility in each specialty. A FM fellowship can not lead to board eligibility by the ABEM. Been discussed ad nauseum in both this and the EM forums.

 

[septoplasty]

A dual residency leads to board eligibility in each specialty. A FM fellowship can not lead to board eligibility by the ABEM. Been discussed ad nauseum in both this and the EM forums.

This.

But do know that doing a fellowship will better prepare you to handle things that walk in on you in that rural location. Also, some hospitals may give you ER privileges if you have certifications not necessarily ABEM certification.

 

[deleted480308]

This.

But do know that doing a fellowship will better prepare you to handle things that walk in on you in that rural location. Also, some hospitals may give you ER privileges if you have certifications not necessarily ABEM certification.

That was part of the question.....i'm not scared of staying in fm, but in a remote location i was wondering if a felliwship like this might help keep someone alive

 

[Makati2008]

I have known people in these fellowships to say the extra training was of little benefit and they wished they went either pure EM or EM/FM.

 

[cabinbuilder]

That was part of the question.....i'm not scared of staying in fm, but in a remote location i was wondering if a felliwship like this might help keep someone alive

This is what I do for a living. Work in remote (frontier) locations. I had an FM residency that was heavy in EM too. You don't need a fellowship to do rural medicine.It's about confidence. I would suggest doing some trauma rotations because most of what I do in a location like that is stabilize and ship. You are not going to "fix" major issues in the bush, you are going to do your best to get them to help quickly. You cannot save everyone and you need to understand that people who live in rural locations take the risk of the possibility of not making it in an emergent situation.

What I think is more important is to be able to read your own CT's and plain xray's. I don't always have the luxury of having a radiologist who gets back to me in a timely manner. I always look at my films and many times have called the plane before the official report is received.

 

[deleted480308]

Thanks cabin.....minus the traveling for locums part I'm hoping to pretty much be in the same situation you seem to do. Assuming i'm still thinking that way come rotation selection time (i've got tons of time till then), i'll probably pm you for a little more specific guidance

 

[NERDY]

Also, take ATLS if you plan on being in a rural area.

 

[cabinbuilder]

Also, take ATLS if you plan on being in a rural area.

This course is not generally required to work in a rural EM - I only found one small hospital in TX who actually required it. Most ER cases in rural areas are more urgent care type. You do get the rare serious event. Take it if you want to but don't feel you have to.

 

[KnuxNole]

The student book for ATLS is soooo dense

 

[Daiphon]

This course is not generally required to work in a rural EM - I only found one small hospital in TX who actually required it. Most ER cases in rural areas are more urgent care type. You do get the rare serious event. Take it if you want to but don't feel you have to.

...but the "rare serious event" is what you need to be able to handle. I'll be the first to admit that many of my patients are urgent-care types; but EM residency prepares you for the Charlie Foxtrots.

If you're gonna be "it" for a large, remote area, then the merit badges are essential IMHO. Take ATLS and write it off on your taxes.

-d

Sent from my DROID BIONIC using Tapatalk

 

[cabinbuilder]

...but the "rare serious event" is what you need to be able to handle. I'll be the first to admit that many of my patients are urgent-care types; but EM residency prepares you for the Charlie Foxtrots.

If you're gonna be "it" for a large, remote area, then the merit badges are essential IMHO. Take ATLS and write it off on your taxes.

-d

Sent from my DROID BIONIC using Tapatalk

I took ATLS - totally hated it. Felt it really didn't help me as much as doing actual rotations in residency and learning to deal with what to do then and there. That's my way of learning. I wasn't saying don't take it, just that having one course without any actual real life experience is not wise either.

Being "it" is what I do. I didn't find the class that helpful.

 

[deleted6669]

I took ATLS - totally hated it. Felt it really didn't help me as much as doing actual rotations in residency and learning to deal with what to do then and there. That's my way of learning. I wasn't saying don't take it, just that having one course without any actual real life experience is not wise either.

Being "it" is what I do. I didn't find the class that helpful.

I took atls right before a 5 week trauma elective and found it immensely helpful in that regard. I work mostly rural at this point and we actually see quite a bit of trauma as we have a major freeway nearby and lots of folks vacationing in the area who can't drive.

 

[PrimaryCare11]

Can't you just do a FM residency with a lot of EM electives?

So how much does an FM doc working rural EM get per hour?

 

[cabinbuilder]

Can't you just do a FM residency with a lot of EM electives?

So how much does an FM doc working rural EM get per hour?

Yes, I did an EM heavy FP residency.

The pay depends on the volume. Most places I work, I don't sit in the ER waiting for patients. I do clinic during the day and then get called in when ER patients show up. The nursing staff triages the patients who walk in. For this I get $100/hr call back pay.

 

[deleted480308]

Yes, I did an EM heavy FP residency.

That sounds like a great plan. Are their indicators to signal a fp residency does a lot of em other than them just saying so?

 

[cabinbuilder]

That sounds like a great plan. Are their indicators to signal a fp residency does a lot of em other than them just saying so?

No, it's up to you to set up your rotations in residency to give you the training you want if you know you are going to do rural medicine. No one is going to tell you what to take. There is a required EM rotation and it up to you to take more than that if you want.

 

[PrimaryCare11]

Cabinbuilder, do you feel pretty comfortable in the ER with the training you got during residency? Are there things that you're not comfortable with doing?

If I do FM, I plan to load up on ER electives as well.

 

[cabinbuilder]

Cabinbuilder, do you feel pretty comfortable in the ER with the training you got during residency? Are there things that you're not comfortable with doing?

If I do FM, I plan to load up on ER electives as well.

Yes, I feel comfortable. But there is always that moment when someone walks in and you are reading furiously in the back trying to figure out what to do.

I had the time when I had to scrape out metal out of a cornea (1st time ever)
The C-1 fracture that walked in the door. The 3/4 amputated arm and the man was bleeding to death in font of us with only 4 units of blood on the island (the plane couldn't get there fast enough) He lived.

When you are out there alone, you do your best, be honest with the patient, and get them where they need to be quickly.

 

[deleted6669]

I had the time when I had to scrape out metal out of a cornea (1st time ever)
.

Surprised you didn't do this as a resident. I have worked at 2 facilities with fp residencies and all the residents rotated through the e.d. pgy-1 and pgy-2 and learned minor procedures like this from the PAs . I probably do this 2-3x/week. pretty easy once you get over any initial squeamishness regarding using an ophthalmic burr. A good way to practice this is by removing dirt pressed into a hard boiled egg using the burr, an eye spud, or an 18 g needle.

 

[BJJVP]

Yes, I feel comfortable. But there is always that moment when someone walks in and you are reading furiously in the back trying to figure out what to do.

That is a funny but very truthful statement. My respect for you just went up a ton because that's such an honest answer. If we were all honest with ourselves, we would probably admit that this happens more than we'd like, regardless of specialty or practice setting.

By the way, I work with very strong PAs and probably only 2 or 3 of them are comfortable removing corneal FBs. In one month of EM, you might not get to see a corneal FB removal. Even if you do, you'd have to see one, do one and maybe even teach one before you're comfortable. 3x/wk for one provider sounds like quite a few eye injuries but maybe it depends on what local industrial jobs are present.

 

[deleted6669]

By the way, I work with very strong PAs and probably only 2 or 3 of them are comfortable removing corneal FBs. In one month of EM, you might not get to see a corneal FB removal. Even if you do, you'd have to see one, do one and maybe even teach one before you're comfortable. 3x/wk for one provider sounds like quite a few eye injuries but maybe it depends on what local industrial jobs are present.

We have 18 PAs in our group and we all do this. the setting is a busy trauma ctr in an urban area with lots of local industry with pts who are welders, sheet metal workers, auto mechanics, etc

 

[cabinbuilder]

Surprised you didn't do this as a resident. I have worked at 2 facilities with fp residencies and all the residents rotated through the e.d. pgy-1 and pgy-2 and learned minor procedures like this from the PAs . I probably do this 2-3x/week. pretty easy once you get over any initial squeamishness regarding using an ophthalmic burr. A good way to practice this is by removing dirt pressed into a hard boiled egg using the burr, an eye spud, or an 18 g needle.

All depends on the residency. Never saw one as a resident.Where I trained the eye clinic had its own 24/7 call and we almost never saw eye injuries in the ER. An ophthalmic burr? Not in your wildest dreams in the locations I work. Was glad to have anesthetic and a needle handy. Got the metal out, patched the eye, the guy got back on the fishing boat with instructions to see the eye doctor (if possible) 2 days boat trip away.

 

[cabinbuilder]

That is a funny but very truthful statement. My respect for you just went up a ton because that's such an honest answer. If we were all honest with ourselves, we would probably admit that this happens more than we'd like, regardless of specialty or practice setting.
QUOTE]

Thanks for that nice comment. I guess for me I understand that I can not know everything but am willing to look it up in a crunch, hold my breath, and do my best since I'm usually in a situation where there is just the family and the nursing staff looking at me to "do something".

It also helps that I grew up in the Alaskan Wilderness (didn't talk on a phone until I was 16, moved to "town" when I was 22) so I understand rural people and what they expect. They know you are there to help and will do your best but sometimes things don't always go right and people die due to lack of services. For living where they do, it's an acceptable trade as long as they feel you tried.

 

[NOsaintsfan]

So Ms. Cabinbuilder, can I get your thoughts on doing something like a combined FM/EM or IM/EM residency.

I ask because I am intrigued by the acute/chronic skill set and the opportunity to work in most non surgical settings. I think it would provide the skill base for being a great small town doc. I realize that 5 yrs as opposed to 3 is a bummer however many EM residencies are 4 yrs so to tack on an extra year to that isn't so crazy. Anyway do you feel like this sort of training is overkill or something that would be truly beneficial if your looking to be the one-stop rural doc?

 

[cabinbuilder]

So Ms. Cabinbuilder, can I get your thoughts on doing something like a combined FM/EM or IM/EM residency.

I ask because I am intrigued by the acute/chronic skill set and the opportunity to work in most non surgical settings. I think it would provide the skill base for being a great small town doc. I realize that 5 yrs as opposed to 3 is a bummer however many EM residencies are 4 yrs so to tack on an extra year to that isn't so crazy. Anyway do you feel like this sort of training is overkill or something that would be truly beneficial if your looking to be the one-stop rural doc?

I would not do IM if you plan to do rural. IM doesn't get training with children and you get lots of sick kids in rural areas. The EM portion may help you with that though. I think FP is much more versatile in what you can do out in the sticks just because the residency is so different.

For me I felt like I got enough ER in my FP residency and I was pro-active in setting my my electives with the knowledge that I would be doing rural medicine - makes a difference. I personally would not have done a 5 yr residency, I got finished at 40 and was tired. Just wanted to be done and start having an income. Now if you have age on your side and feel that you may want to be practicing in a larger ER - then by all means do the combined residency. For where I work and what I see, it would have been overkill for me.

 

[deleted109597]

Yes, I did an EM heavy FP residency.

What exactly does this mean? How many months of EM did you do?

 

[VenturaResident]

I'm also at an EM-heavy FM residency. For us, that means every resident automatically is scheduled for >800 hours in the ED during residency not counting any extra elective time. (For comparison, the ACGME requires only 200 hrs for FM grads.) Also, all interns get ATLS certified and run trauma codes (we're a Level II Trauma Center). That works out to a full month each year plus maybe 100 extra hours during intern year. On top of that, we all do Urgent Care work starting second year. Third years often moonlight in the ER. And usually there is someone doing extra elective ER time like practicing FAST scans in traumas or whatever. It makes a huge difference in how competent folks are for working ER when they graduate.

 

[deleted6669]

I'm also at an EM-heavy FM residency. For us, that means every resident automatically is scheduled for >800 hours in the ED during residency not counting any extra elective time. (For comparison, the ACGME requires only 200 hrs for FM grads.) Also, all interns get ATLS certified and run trauma codes (we're a Level II Trauma Center). That works out to a full month each year plus maybe 100 extra hours during intern year. On top of that, we all do Urgent Care work starting second year. Third years often moonlight in the ER. And usually there is someone doing extra elective ER time like practicing FAST scans in traumas or whatever. It makes a huge difference in how competent folks are for working ER when they graduate.

Congrats on matching to Ventura. I think it is likely the best unopposed FM residency in the country for someone looking at a future in full scope family medicine. I used to take patients there as a medic and the family medicine residents run that place. Much more competent at managing acute pts than I have seen at any other family medicine residency I know of, and I have been involved with several on the west coast.
I didn't realize the FM requirement was so low (200 hrs?). I did > 1000 hrs just in PA school between EM, Peds EM, and an EM elective, not to mention 600 hours of trauma surgery.

 

[deleted109597]

Again, this is where the EM residency guys get to be dismayed by what is considered "adequate".
Sure, 800 hours may be a lot. But the average EM resident does ~3600 supervised hours to be eligible to sit for their boards. If we want to decrease the required time to be competent to what the "heavy" programs think is enough, we could do our residency in less than a year.
While we respect those willing to go work in rural areas, and aren't trying to take that away from the FM guys, we also don't want the FM fellowships to be a back door into certification. It is a not so well guarded secret that the only reason FM grads do those fellowships is so they can work in places that won't accept simply being FM trained, and usually these are the bigger hospitals or those in larger cities. The fellowships (just like allowing independent practice for NPs, etc) like to endorse that they're promoting medicine in underserved areas, but this simply isn't what happens.

 

[EdibleEgg]

Again, this is where the EM residency guys get to be dismayed by what is considered "adequate".
Sure, 800 hours may be a lot. But the average EM resident does ~3600 supervised hours to be eligible to sit for their boards. If we want to decrease the required time to be competent to what the "heavy" programs think is enough, we could do our residency in less than a year.
While we respect those willing to go work in rural areas, and aren't trying to take that away from the FM guys,we also don't want the FM fellowships to be a back door into certification. It is a not so well guarded secret that the only reason FM grads do those fellowships is so they can work in places that won't accept simply being FM trained, and usually these are the bigger hospitals or those in larger cities. The fellowships (just like allowing independent practice for NPs, etc) like to endorse that they're promoting medicine in underserved areas, but this simply isn't what happens.

You probably could complete residency in a year if there was no value in any other rotation. If heart failure was a totally different entity once it crossed the threshold of the emergency department, you might be right. You cant completely devalue anything other than EM rotations.

It's obvious your only concern is turf. It's a little paranoid to think that 2 or 3 EM fellowships would produce enough docs to have any effect on your job market. I'm not worried about a nurse practitioner taking my job. I know I can do things they can't. If an EM residency makes you such a superior physician, then you have nothing to worry about either.

 

[deleted109597]

It's obvious your only concern is turf. It's a little paranoid to think that 2 or 3 EM fellowships would produce enough docs to have any effect on your job market. I'm not worried about a nurse practitioner taking my job. I know I can do things they can't. If an EM residency makes you such a superior physician, then you have nothing to worry about either.

Nope, our concern is about the patients. If they're seeing someone in an Emergency Department, they should seen an Emergency Physician (if they're having an emergency. I'll concede that not everyone coming in needs one.)
I don't see FM out there trying to do unaccredited cardiology fellowships, then sitting for an unrecognized cardiology board and petitioning the state to put them on equal standing with the ABMS cardiologists. But it happens frequently with EM.
Again, there aren't enough EPs out there to work everywhere. If the option is nobody, or somebody with less training, I'll pick the warm body over nothing. However, to imply that they're equal by trying to shoehorn their way into board certification is at best dishonest, and at worst flat out dangerous.
Train in the field you want to do, not the backdoor way into something else.

 

[deleted480308]

Nope, our concern is about the patients. If they're seeing someone in an Emergency Department, they should seen an Emergency Physician (if they're having an emergency. I'll concede that not everyone coming in needs one.)
I don't see FM out there trying to do unaccredited cardiology fellowships, then sitting for an unrecognized cardiology board and petitioning the state to put them on equal standing with the ABMS cardiologists. But it happens frequently with EM.
Again, there aren't enough EPs out there to work everywhere. If the option is nobody, or somebody with less training, I'll pick the warm body over nothing. However, to imply that they're equal by trying to shoehorn their way into board certification is at best dishonest, and at worst flat out dangerous.
Train in the field you want to do, not the backdoor way into something else.

I totally get your concern there

 

[cabinbuilder]

Cabinbuilder, do you feel pretty comfortable in the ER with the training you got during residency? Are there things that you're not comfortable with doing?

If I do FM, I plan to load up on ER electives as well.

Yes, but I would never say that I am on the same level as an ER trained doc - I am not. With knowing that, I would never take a job in a large hospital or trauma center, that's just not what I do nor is it safe.

I only do ER in rural critical care access hospitals that have max 3 rooms. Any ER larger than that their volume to too much for what I was trained to do.

On the flip side of that I was in a situation where there was an ER doc doing inpatient, ER and FP clinic at the same small facility. Seemed kind of odd to me since ER docs don't do inpatient. I was given report that they admit a patient in DT's and they were watching the patient the "sleep it off" for the last 3 days. Okay......... by the time I finished rounding on everyone, etc. I ended up doing a medevac on the "DT" patient who was pancytopenic with pneumonia and extremely high LFT's, unresponsive. Not a situation I was expecting where I didn't have any FFP and only 4 units of blood. He got transferred that day.

 

[Hamhock]

If heart failure was a totally different entity once it crossed the threshold of the emergency department...

It is ironic that you chose "heart failure" as an example of a disease process that you think is similar on the inpatient and outpatient/ED.

In fact, heart failure is very different (most of the time) when it crosses the threshold from the ED to the inpatient side.

Not the slow-onset, volume-overload from eating 16 cheeseburgers with a side of sweet-and-sour pork per day -- but the acute, sympathetic surge "failure"/APE...

Most EM docs realize this APE is not volume overload...most inpatient docs are pushing lasix and planning to intubate, whereas most EM docs toss on a little CPAP/BiPAP and a nitro drip at 200, wait an hour, and then admit to tele with the patient on nasal cannula at 2L...just waiting to hear from the hospitalist, "No lasix?!"

This disease process is very different once it crosses the threshold form the ED to the inpatient side; unless an inpatient/non-EM doc is managing it in the ED -- then it is an unnecessary CCU/MICU admission.

HH

 

[deleted6669]

I only do ER in rural critical care access hospitals that have max 3 rooms. Any ER larger than that their volume to too much for what I was trained to do.

Wow, 3 beds is truly tiny. I work at 2 critical access facilities per diem. one is 5 beds, one is 9 beds.
the ER on Catalina island is 2 beds. FM docs do shifts 1 week long with a weekly census of around 7.
worth looking into if you are in that part of the world.

 

[cabinbuilder]

Wow, 3 beds is truly tiny. I work at 2 critical access facilities per diem. one is 5 beds, one is 9 beds.
the ER on Catalina island is 2 beds. FM docs do shifts 1 week long with a weekly census of around 7.
worth looking into if you are in that part of the world.

I don't have a California license, have no desire to get one. Like I said, I do frontier medicine mostly, especially if I'm asked to to ER.

 

[EdibleEgg]

Nope, our concern is about the patients.

Sorry, but I just don't believe you. You are also wrong that the only reason to people choose to do the EM fellowship is as a back door to competing with you. Rural medicine is different, training for that difference is good for patients and not dishonest.

It is ironic that you chose "heart failure" as an example of a disease process that you think is similar on the inpatient and outpatient/ED.

This disease process is very different once it crosses the threshold form the ED to the inpatient side; unless an inpatient/non-EM doc is managing it in the ED -- then it is an unnecessary CCU/MICU admission.

HH

Thanks for the lesson bro, but I've got it. The management of acute and chronic heart failure is different, but there's nothing magic above moving a patient down the hall. Anyway, not my point.

 

[deleted109597]

Sorry, but I just don't believe you. You are also wrong that the only reason to people choose to do the EM fellowship is as a back door to competing with you. Rural medicine is different, training for that difference is good for patients and not dishonest.

Sure. You show me the statistics that show how many people do the fellowship and then practice in rural areas. I'll wait.

And they're not competing with me. They are competing with the community guys. I've been to the state meetings. I listened to them try to argue why they should be allowed to advertise as board certified in Texas after completing their "practice track".
Again, why aren't you arguing for fellowships in other specialties? Or practice track board eligibility?

 

[deleted480308]

I think part of the reason so many fm doc feel comfortable in transitioning to em is because a lot of the patients in an er are actually there for primary care reasons. Sore throats, med refills, minor cruts, sprains, and then some drug seekers. I shadowed in a large lvl 1 trauma center and they had an entire section of the er that was staffed by np/pa precisely because so many of the patients were not an "emergency". A physician would just round over there every 45 and double check treatment with the np. But not everyone was that type of patient, there were some pretty crazy "i'm dead in 5 minutes if someone doesn't fix it" patients. And if i'm that patient I probably want a full em residency doc around. I'm glad we're all admitting that some little towns don't have the luxury of that, which is why I asked about the em fellowship for fm docs.

I still don't think that means I'd staff a 4 doc dept with only em fellowship trained fm docs......but the comparison to other specialties is not really seeming representative to me

 

[deleted6669]

I still don't think that means I'd staff a 4 doc dept with only em fellowship trained fm docs......

No offense to anyone here but if you are staffing a low volume ER without other clinic or hospital responsibilities a well trained EM PA makes a lot more sense than a family medicine physician.
A senior em pa with 10+ years on the job and prior experience in ems has likely had much more exposure to emergency medicine, difficult airways and emergent procedures than a typical family medicine physician. A pa focused on em can accrue several thousand hours of training specific to emergency medicine even before they graduate from pa school. earlier in this thread someone mentioned that the fp residency requirement for em is 200 hours. I had over 1000 em hours in addition to a 600 hr trauma surgery rotation just in pa school as well as all the standard primary care rotations after being a medic for 10 years in busy 911 systems.
Since graduation I have seen over 125,000 pts in ER's ranging from rural critical access 5 bed depts to level 1 trauma centers.
Typical EM PAs do ALL of their cme in EM and attend yearly conferences like ACEP scientific assembly.
most PA folks I know who work solo have the following recent certs:
Advanced Cardiac Life Support (A.C.L.S.)
Advanced Trauma Life Support (A.T.L.S.)
Advanced Pediatric Life Support (A.P.L.S.)
Pediatric Advanced Life Support (P.A.L.S.)
Advanced Burn Life Support (A.B.L.S.)
Fundamental Critical Care Support (F.C.C.S.)
Advanced Life Support in Obstetrics (A.L.S.O.)
Basic Disaster Life Support (B.D.L.S.)
The Difficult Airway Course
FAST Plus Emergency Ultrasound Course

I agree that if you throw clinic and hospital rounding into the mix that the doc makes more sense. Throwing a typical recently graduated family medicine physician who did not do an em heavy fp residency into a solo coverage em situation really isn't fair to them or to their patients. Stuff em pas do routinely many fp docs never did in residency. see the discussion above about FB removal from the eye. this is a fast track level procedure any senior em pa has done hundreds if not thousand of times. ditto fracture and dislocation reduction, regional blocks, etc
I work long shifts (12-24 hrs) at 2 small emergency depts that staff docs and PAs interchangeably. When they can get experienced PAs they pay us around 75/hr. When they can't get us they use FP docs who make considerably more. They don't have the volume or resources to attract residency trained/board certified em docs which I agree would be the gold standard. I agree that FP em fellowship trained folks are gold in the rural environment. I have worked with a few who are excellent. there just aren't that many out there. The ones I know are directors of rural ERs and actually do more admin than clinical work at this point. my comments above RE: EMPA vs FP MD were about FP docs without the fellowship.
Even well known facilities in rural environments are going to this staffing model. This is a PA run Mayo clinic affiliated Emergency dept that was ranked among the top small depts in the country a few years ago:
http://www.startribune.com/lifestyle/37374164.html
from the above article: "In 2007, one in seven rural hospitals had only PAs or nurse practitioners staffing their emergency rooms, according to a national survey by the University of Minnesota's Rural Health Research Center."
The "on call doctors" available as back up are the same hospitalists who were on call when the dept was physician staffed. many of these places (and both places I work) have an on call hospitalist and an on call general surgeon available to respond to the dept within 20 min.
needless to say, for folks with issues that can't wait 20 min who need a higher level of care the helicopter is only a phone call away. Most of these places, whether PA or physician staffed, serve to stabilize and ship pts with significant trauma, stemi's, cva's, etc.
We have thrombolytics in the dept which we use after appropriate consultation with the receiving neurologists or cardiologists.
I have lots of respect for family medicine physicians. they are great at what they do and what their training focuses on. for most of them though that is not patients with emergent conditions. If I were to go back to medschool(pretty unlikely at this point) I would do an unopposed full scope family medicine residency like Ventura county and do exactly what cabin builder above does; cover small rural hospitals as the only doc in town seeing all comers in the clinic, er, icu, ob, etc.

 

[cabinbuilder]

I'm hoping to become a rural primary care doc but I also know that EM medicine opens a lot of doors for practice locations. I've noticed that there are now dual FM/EM residency programs and something that I just saw where there are 1yr fellowships in EM for FM docs.

Can someone shed some light on the difference between those two paths and if you personally see any benefit/nonbenefit to the two? Can both be EM boarded? Do you need even need EM credentials to work an EM in a small town?

I think with all the hostility in this thread we need to go back to the original questions.

If you do FP with an EM fellowship you would not be EM boarded, just FP with the knowledge that you took the time to learn more ER for personal gain. I don't think the OP was trying to imply that FP with fellowship deserved to be double boarded.

And I'm sorry that some think its an atrocity that I have never scraped out a FB in an eye. Well I didn't spend my whole residency in the ER like an ER PA and we didn't get eye cases in the ER because the local ophthomologists had great 24/7 coverage and own eye "ER" in their office building. Doesn't make me a bad doctor, just means I didn't have opportunity to see that type of case. I read what to do and took care of the patient as I was expected to do.

I think the other thing is that there seems to be a discrepancy about what is "rural" and what is "frontier".

To clarify I have never, and will never just work in an ER. That is too much volume for what I like and as the above posters have stated, those types of jobs are better suited for ER trained DR/PA who deal with the chest tubes, MI's, strokes, and trauma cases every day. Most rural hospitals are busy enough to have 24/7 ER staff whether locums or perm.

Frontier medcine is a whole different entity that is better suited for FP since when I'm out on the site I am covering the entire entity: generally a 2-3 bed ER, clinic during the day, admit my own patients, and any long term care patients. My purpose in a true emergency in these cases is to stabilize and ship so the patient lives to get to the next level of care. Most hospitals I work at don't have ICU either. I can do ICU medicine but usually I'm limited by the knowledge of the nursing staff.

 

[cabinbuilder]

No offense to anyone here but if you are staffing a low volume ER without other clinic or hospital responsibilities a well trained EM PA makes a lot more sense than a family medicine physician.
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This scenario really doesn't exist if the volume is that low. It's not economical.

Ok, so where in the hell are you going to get an EM PA as good as you in Southeast Alaska, the Alaska Peninsula, Northen Alaska, Northern or Eastern Montana, the center of Colorado, the center of Nevada, southern Idaho, SW Texas, Western Oregon, New Mexico, or Arizona? You aren't because those sites need more coverage than just ER. Sure you go to Catalina Island but that is a far cry from Barrow.

In doing locums the last 4 years at 20+ sites I have only once come across an ER PA who I will admit had more experience than me and I was glad he was there.

Just venting today. My cabin is burning it seems.........

 

[deleted6669]

This scenario really doesn't exist if the volume is that low. It's not economical.

Ok, so where in the hell are you going to get an EM PA as good as you in Southeast Alaska, the Alaska Peninsula, Northen Alaska, Northern or Eastern Montana, the center of Colorado, the center of Nevada, southern Idaho, SW Texas, Western Oregon, New Mexico, or Arizona? You aren't because those sites need more coverage than just ER. Sure you go to Catalina Island but that is a far cry from Barrow.

In doing locums the last 4 years at 20+ sites I have only once come across an ER PA who I will admit had more experience than me and I was glad he was there.
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I'm not dumping on you, I was speaking in generalities. I'm sure you are great at what you do and any facility that gets you is lucky to do so. sorry to harp on the eye fb issue. it was just an example. the fp residents at my primary job do a lot of these when they rotate through the er because our ophtho coverage sucks. they will pretty much only come in if they know they need to go emergently to the o.r.
just as an fyi, many of the best solo em pa jobs are in the states you mentioned above. I have several friends as good or better than I am doing work in alaska, oregon, washington, montana, maine vermont, michigan, etc. at ERs that see 2-20 pts/24 hrs.
As an example, I have 3 friends who work solo coverage jobs in the aleutians. they are it. nearest doc is 6 hrs away by plane if the plane can even fly due to weather. in that setting they also do a lot of what you do(general med clinic, occ. med., etc) but were hired mostly for their em skills.
do you know about the clinic in fossil oregon that is always hard up for providers? they will provide housing to folks willing to stay a min of 2 weeks. they staff whoever they can get, PA or MD.
I agree that the frontier setting as you describe it is much better suited to an fp md than another type of provider.

 

[cabinbuilder]

I'm not dumping on you, I was speaking in generalities. I'm sure you are great at what you do and any facility that gets you is lucky to do so. sorry to harp on the eye fb issue. it was just an example. the fp residents at my primary job do a lot of these when they rotate through the er because our ophtho coverage sucks. they will pretty much only come in if they know they need to go emergently to the o.r.
just as an fyi, many of the best solo em pa jobs are in the states you mentioned above. I have several friends as good or better than I am doing work in alaska, oregon, washington, montana, maine vermont, michigan, etc. at ERs that see 2-20 pts/24 hrs.
As an example, I have 3 friends who work solo coverage jobs in the aleutians. they are it. nearest doc is 6 hrs away by plane if the plane can even fly due to weather. in that setting they also do a lot of what you do(general med clinic, occ. med., etc) but were hired mostly for their em skills.
do you know about the clinic in fossil oregon that is always hard up for providers? they will provide housing to folks willing to stay a min of 2 weeks. they staff whoever they can get, PA or MD.
I agree that the frontier setting as you describe it is much better suited to an fp md than another type of provider.

Its' ok. I'm having kind of an ugly day in urgent care. Hostile patients. Haven't heard about fossil. I have multiple locums companies who place me so it all comes down to who has their contracts. I always have my housing, travel and care paid for by the site so that's not usually an issue for me. I work 6-10 weeks at a time so a 2 weeks stint isn't worth all the credentialling needed to place me.

Yes, the FB comments irked me. I'm sure I've seen plenty what others haven't: 2 cases of typhus, shark bite, 2 cases of pseudomyxoma peritonii, untreated basal cell that eroded through to the thecal sac, measles, fornier's gangrene, pickwickian syndrome, bear maul, total body frostbite, 2 cases of Stevens-Johnson syndrome. It all comes down to the type of hospital and the patient population.

 

[EdibleEgg]

Sure. You show me the statistics that show how many people do the fellowship and then practice in rural areas. I'll wait.

And they're not competing with me. They are competing with the community guys. I've been to the state meetings. I listened to them try to argue why they should be allowed to advertise as board certified in Texas after completing their "practice track".
Again, why aren't you arguing for fellowships in other specialties? Or practice track board eligibility?

I don't know that anyone has those statistics. There are a relatively small number of physicians completing rural/EM fellowships every year. We are a relatively tight knit group. Of the 6-7 that stay in touch, NONE of us are in urban areas. You said the only reason anyone completes the fellowship is for a back door into better jobs. That's simply not true. I finished a family medicine residency, then did a couple years of rural/frontier locums. There were lots of things I was not comfortable with, so I went back for the fellowship.

Arguing for other fellowships? Maybe. I think there should be more opportunities to learn. Board certification? Your fetish with that is what makes me think you are more concerned with turf than patients. It worries me that you are in academic medicine. I hope you are not the guy that pushes the off service resident to fast track and forgets about them until shift change.

 

[EdibleEgg]

No offense to anyone here but if you are staffing a low volume ER without other clinic or hospital responsibilities a well trained EM PA makes a lot more sense than a family medicine physician.

I'm not going to argue that point, but you are not the average PA.

 

[deleted6669]

I'm not going to argue that point, but you are not the average PA.

Agreed. that's why I referenced "well trained senior em pa". this is not a job for a new grad pa or a pa without prior em background who only does fast track jobs. most(if not all) of these folks are former 911 paramedics or military medics, er nurses, or resp. therapists.
there are 10,000 em pas in the country. probably 5 % or 500 of us are up for this type of job. that's still 10/state if you spread us around although most of us probably work in maybe a dozen states with good pa legislation. it's a small community of folks. I know many of them as we attend the same cme events and compete for the same jobs.
it takes a lot of looking/connections to land a job like this. For one of my rural jobs I was on a waiting list for 10 years waiting for other folks to leave.
ps : if you completed an fp em fellowship you are not the avg fp md. in post #41 I did say "my comments above RE: EMPA vs FP MD were about FP docs without the fellowship."

I would have no problem working for you or losing a job to someone with your background. I know places hire folks like me as a stop gap measure because they can't get or can't afford providers with more training. I'm confident there will always be jobs for folks in my situation as well as those family medicine physicians who seek out this type of job.
did you attend one of the TN programs?

 

[deleted109597]

I don't know that anyone has those statistics. There are a relatively small number of physicians completing rural/EM fellowships every year. We are a relatively tight knit group. Of the 6-7 that stay in touch, NONE of us are in urban areas. You said the only reason anyone completes the fellowship is for a back door into better jobs. That's simply not true. I finished a family medicine residency, then did a couple years of rural/frontier locums. There were lots of things I was not comfortable with, so I went back for the fellowship.

Arguing for other fellowships? Maybe. I think there should be more opportunities to learn. Board certification? Your fetish with that is what makes me think you are more concerned with turf than patients. It worries me that you are in academic medicine. I hope you are not the guy that pushes the off service resident to fast track and forgets about them until shift change.

Again, if you want to claim that I'm making up the legal battles the AAPS has had trying to fight for the right to claim board certification in states, then feel free. If you want to compare the number of emergency medicine "board certifications" that group gives compared to the other specialties, they won't tell you. AAEM had some old numbers of close to 80%.
If you want to do the fellowship to learn better how to practice something you didn't train in, it's reasonable. Then I ask why you didn't train in it, if you wanted to do it.
All I'm arguing for is you to set a benchmark. Either EM residents vastly overshoot what you consider competency, or FM residents undershoot it. If you want to claim different standards for different areas, you might have an audience, but most lawyers won't uphold the "well, we don't usually have any emergencies at this places, so..."
Poorly trained doctors were the reason ATLS was invented. It wasn't necessarily their fault then, as the training didn't exist. But it is the fault of the person doing the job they aren't adequately trained in.
We use the same argument in Texas currently to argue that there should be a person staffing every emergency department in the state 24/7. If someone sees a +, they should expect someone to be there that can adequately manage their emergency. Not a 30 minute response time. Not somebody that can't perform the job.
Remember the OP?

Can both be EM boarded?

Which one of us brought up board certification first?

 

[EdibleEgg]

If you want to compare the number of emergency medicine "board certifications" that group gives compared to the other specialties, they won't tell you. AAEM had some old numbers of close to 80%.

I don't know much about AAPS and I don't really care. I don't see how that has anything to do with this conversation.

If you want to do the fellowship to learn better how to practice something you didn't train in, it's reasonable.

During med school and residency, I spent literally hundreds of hours in the ED, and hundreds more taking care of emergency issues outside of the emergency department. I wanted to be better. Emergency medicine was not the focus of my fellowship, but it was a big part. I know the additional training has made a difference in the lives of my patients.


Then I ask why you didn't train in it, if you wanted to do it.

An emergency medicine residency wound not have trained me well for what I do. Maybe one the the dual programs, but not EM alone.

All I'm arguing for is you to set a benchmark. Either EM residents vastly overshoot what you consider competency, or FM residents undershoot it.

You don't understand what competency means. Board certification does not equal competency. Competency is the ability to do a job properly. I doesn't mean that you are going to pass the test just because you took the class.

If you want to claim different standards for different areas, you might have an audience, but most lawyers won't uphold the "well, we don't usually have any emergencies at this places, so..."

Standards are not different, but practice is. If you have an unstable UGI bleed, I'm guessing you have a hungry GI fellow tucked away upstairs. With lights and sirens I'm three hours away.


Poorly trained doctors were the reason ATLS was invented. It wasn't necessarily their fault then, as the training didn't exist. But it is the fault of the person doing the job they aren't adequately trained in.

Well, I'm not poorly trained. Are you saying that ATLS is a bad thing?

We use the same argument in Texas currently to argue that there should be a person staffing every emergency department in the state 24/7. If someone sees a , they should expect someone to be there that can adequately manage their emergency. Not a 30 minute response time. Not somebody that can't perform the job.

I don't know exactly what your argument you are refering to, but I agree that every emergency department should be staffed by someone adequately prepared to manage emergencies.

Remember the OP?
Which one of us brought up board certification first?

Diphenyl answered the OP's question very appropriately at the beginning of the thread. Your addition was inaccurate. The OP never said that fellowship should lead to ABEM certification.

Sure, 800 hours may be a lot. But the average EM resident does ~3600 supervised hours to be eligible to sit for their boards.

Fair enough. Again, no one here has argued for in favor of ABEM certification for all.

If we want to decrease the required time to be competent to what the "heavy" programs think is enough, we could do our residency in less than a year.


Yes, and I really think you would generally be a good group of docs as long as you did a family medicine residency first.

While we respect those willing to go work in rural areas,
I have my doubts that you do.

and aren't trying to take that away from the FM guys,
That doesn't fit in with the rest of your comments.

we also don't want the FM fellowships to be a back door into certification.

Again, no one is arguing for that.

It is a not so well guarded secret that the only reason FM grads do those fellowships is so they can work in places that won't accept simply being FM trained, and usually these are the bigger hospitals or those in larger cities.

You are just wrong. You have no idea.

The fellowships (just like allowing independent practice for NPs, etc) like to endorse that they're promoting medicine in underserved areas, but this simply isn't what happens.
Show me your statistics, I'll wait.[/QUOTE]