EM fellowships for FM docs...

[EdibleEgg]

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?

Yes, there will be jobs, especially for those of us that have a passion for this. There certainly no shortage now. I did a rural fellowship not EM. I still practice full scope family medicine with the exception of OB, but the ED has become an increasingly large part of what I do over the last couple of years.

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[Medstar911]

I was pointed to this website by an FM resident who I precept that I did NOT allow to work in my ED upon graduation.

I'm a family medicine trained physician who practices full time at an EM/Hospitalist program (yes... treat the patient in the ED..admit if needed, and round on them).. average ED volume is 9000/year and 8-13 inpatients/day census. I'm the county EMS director, the ED Medical Director and the Hospitalist Medical Director.

Also am senior staff physician at a university affiliated FM residency program where I did my training.

The reason I wouldnt allow my FM resident is because he didn't have enough ED/ICU/Critical care experience neccessary to adequately cover my ED.

Rural Emergency Medicine is NOT urgent care. When you have a 3 year old asthmatic brought in tanking with an O2 sat of 60%, you better know what the heck you're doing.
When people choose to go to an ED, they expect a provider who knows how to handle their emergency. If you can't handle, please don't risk patient safety.

With that being said... the role of my physician group is different. ED patient care and Inpatient. The best docs for this are dually trained EM/IM or EM/FM. Second best are FM residency trained with VAST ED experience (usually look at 2000 hours over 3 years) with documented procedure logs, certifications, etc. Third are EM residency trained with recent inpatient (usually that's senior level ED residents or recent ED grads).

So there's a lot of overlap between the two specialties, but you have to respect that there are major differences between the two.

EM started off with FM and IM physicians covering ED's until there became official residencies. So there are "legacy ED physicians" who are grand-fathered in ABEM physicians who are primary care trained but lifelong ED practicing. For a long time, ABEM respected their founders and their foundation in primary care. Now they've become more concerned with protecting their "turf"...the ED. It's about patient safety, #1. But even if the physician in the ED is a primary care trained physician who's been practicing EM full time for 20+ years...they'd rather have an ED trained physician fresh out of residency....lately they've been pushing for PA/NPs (who are "trained" in EM) to cover EDs rather than primary care trained with vast ED experience. Again, it's about job security.

I'm very comfortable with the right physician covering. So if you're a FM residency trained physician, please do at least a 1 year EM fellowship or obtain >2000 hours in EM experience. In addition, I require ACLS, ATLS, PALS/APLS, prefer also ALSO, Fundamentals of Critical Care, EM Ultrasound training (we utilized ultrasound for FAST exams, LPs, lines, etc.....ultrasound is a MUST).
I don't care if a physician is certified by AAPS, if you're not up on the latest EM best practices/standards of care, I wont accept you in my ED. I have high standards, with the reason being patient safety.

Whatever field you're practicing in, preferably you'd be board certified, not just residency trained. If you're not board certified, you had better increase your knowledge/fundamental for PATIENT SAFETY.

No matter what, ED residency trained physicians despise the fact that you'll be practicing EM in any capacity. You have to see their point...they did EM residency, you didn't. You can run an urgent care, primary care clinic, do hospitalist work....they can't do most of that. So to add on the fact that you can practice EM? They don't really appreciate it

It's a window that will eventually close....EM residency trained physicians will eventually flock to rural EDs because they'll get sick of the inner city stress. But until then, non EM trained can still cover and make a pretty decent living.

 

[deleted6669]

It's a window that will eventually close....EM residency trained physicians will eventually flock to rural EDs because they'll get sick of the inner city stress. But until then, non EM trained can still cover and make a pretty decent living.

I don't know about that. I don't know too many residency trained/boarded em docs who will work for the 80-100/hr many rural EDs pay. I work at 2 rural EDs. both use FM docs and pay them only slightly more than they pay me, on the order of an extra 20 dollars/hr or so.

 

[cabinbuilder]

It's a window that will eventually close....EM residency trained physicians will eventually flock to rural EDs because they'll get sick of the inner city stress. But until then, non EM trained can still cover and make a pretty decent living.

I seriously doubt this as well. No rural ER is going to pay for an EM only trained doc to sit there and wait for the 4 patients to come through the door. When they can hire a FM doc to run the clinic, do inpatient medicine, cover their nursing home and see the few who trickle into the ER inbetween. It's just more economic for the site.

 

[Medstar911]

I seriously doubt this as well. No rural ER is going to pay for an EM only trained doc to sit there and wait for the 4 patients to come through the door. When they can hire a FM doc to run the clinic, do inpatient medicine, cover their nursing home and see the few who trickle into the ER inbetween. It's just more economic for the site.

Those are some pretty lowball payscales.

No doc, whether EM or FM trained will touch a 9k volume for under 140/hr.
for inpatient rounds there's a bonus per patient rounded on in addition to the hourly rate.

I prefer PA to NP any day, however I wouldnt trust a PA alone in a rural ED, no matter how much experience he/she has. No offense to any MLP visiting here.

 

[cabinbuilder]

Those are some pretty lowball payscales.

No doc, whether EM or FM trained will touch a 9k volume for under 140/hr.
for inpatient rounds there's a bonus per patient rounded on in addition to the hourly rate.

I prefer PA to NP any day, however I wouldnt trust a PA alone in a rural ED, no matter how much experience he/she has. No offense to any MLP visiting here.

I have never seen any rural place offer $140/hr for low volume.
What I have worked though, is rural clinic with ER call 24/7 for multiple days straight (the most I have done in a row is 26 days) and got paid around the clock. So I make my money for straight clinic pay+ER call back pay+call pay which has not been previously mentioned here.

 

[Makati2008]

Agree with CB most rural places can't afford to pay 140/hr.

 

[Makati2008]

Those are some pretty lowball payscales.

No doc, whether EM or FM trained will touch a 9k volume for under 140/hr.
for inpatient rounds there's a bonus per patient rounded on in addition to the hourly rate.

I prefer PA to NP any day, however I wouldnt trust a PA alone in a rural ED, no matter how much experience he/she has. No offense to any MLP visiting here.

No offense taken but I think it's funny that many EPs don't think a FP belong in an ED and then you say the same to the MLPs. Just ironic.

 

[MJB]

I'm trying to remember how many times I've seen it asked (by EM residents or aspiring EM residents) how hard it would be to "just become a GP after I burn out in the ED"....and chuckling at all the hostility from EM docs in this thread trying to protect their turf.


I thank God there are people that CHOOSE to work the silly hours and deal with the silly patients that frequent ER's for a living. If you're so worried about turf, staff the rural ED's and quit sticking to the city.


As for interchangeability, it's pretty obvious that FM is MUCH more qualified to cover an ED than an EM is to do primary care because the VAST majority of ER visits are visits that belong in same day clinic.

 

[Makati2008]

I'm trying to remember how many times I've seen it asked (by EM residents or aspiring EM residents) how hard it would be to "just become a GP after I burn out in the ED"....and chuckling at all the hostility from EM docs in this thread trying to protect their turf.


I thank God there are people that CHOOSE to work the silly hours and deal with the silly patients that frequent ER's for a living. If you're so worried about turf, staff the rural ED's and quit sticking to the city.


As for interchangeability, it's pretty obvious that FM is MUCH more qualified to cover an ED than an EM is to do primary care because the VAST majority of ER visits are visits that belong in same day clinic.

The last paragraph is the misnomer about EM IMHO. I personally think both have their place and shouldn't be interchanged if that can be avoided. I wouldn't trust an average EP to manage HTN/DM chronically like I wouldn't trust an average FP intubating a tough airway....

I plan on doing rural EM as an EP with one shift a week in the city to keep all my skills up to par.

 

[Medstar911]

No offense taken but I think it's funny that many EPs don't think a FP belong in an ED and then you say the same to the MLPs. Just ironic.

What's ironic about it? I'd rather a PHYSICIAN cover the ED than a non-physician.

Similar analogy: Would you rather the chef be responsible for making your dinner or would you rather have the chef's secretary make your dinner?

 

[Medstar911]

The last paragraph is the misnomer about EM IMHO. I personally think both have their place and shouldn't be interchanged if that can be avoided. I wouldn't trust an average EP to manage HTN/DM chronically like I wouldn't trust an average FP intubating a tough airway....

I plan on doing rural EM as an EP with one shift a week in the city to keep all my skills up to par.

Completely agree. There is just too much of a difference between the management of the "serious stuff" to say EM and FM are the same.

For those that say EM is just urgent care, that'll change when you're trying to place 2 chest tubes on a patient with bilateral pneumothorax post MVA. If you're going to work in the ED as a non-EM trained physician, please take some extra educational courses/fellowship/etc before working. You're risking patients' lives and your career can get shot down by a malpractice attorney for screwing up royally.

This is coming from an FM trained physician who practices EM full time.

 

[Medstar911]

Agree with CB most rural places can't afford to pay 140/hr.

You must not be very familiar with the market rate in certain geographic areas or volumes. Some rural places I've worked at pay $170/hr, thats for a routine shift.

For critical shifts that need immediate coverage, I've had rural physicians negotiate for as high as $220/hr for a 24 hour shift.

 

[cabinbuilder]

You must not be very familiar with the market rate in certain geographic areas or volumes. Some rural places I've worked at pay $170/hr, thats for a routine shift.

For critical shifts that need immediate coverage, I've had rural physicians negotiate for as high as $220/hr for a 24 hour shift.

I guess it comes down to what your definition of rural is? Do you provide your own housing and travel for that job? Most places I work I have housing, travel, rental car provided so my hourly wage is lower since I have no cost to me. Makes a difference. I can see the higher wage if that's all the site is responsible for.

 

[cabinbuilder]

For critical shifts that need immediate coverage, I've had rural physicians negotiate for as high as $220/hr for a 24 hour shift.

Well of course, desperation brings higher wages but that is not the norm. Any numbers can be negotiated on short notice when coverage is needed now.

 

[deleted6669]

What's ironic about it? I'd rather a PHYSICIAN cover the ED than a non-physician.

So you would prefer a new grad fp doc with 200 hrs in the er over their residency or a dermatologist or a pathologist to an em pa with 25 yrs experience and > 125,000 pt contacts in the ER who was a former paramedic in a busy 911 system and has worked in all em settings from level 1 down to level 4?
not all docs are better prepared to work in the er than an em pa. read the rest of this thread(specifically my post #41) and then comment.....some fp docs are great in the er. some I wouldn't want to place in that setting, ditto pas and np's but some of us are actually up to the task and do it well. I am scheduled interchangeably with docs at 2 of my jobs and am frequently told by the staff that they prefer me to several of the physicians there...I learn a lot from many of the docs I work with and they also learn from me.

 

[deleted87716]

So ..em pa with 25 yrs experience and > 125,000 pt contacts in the ER who was a former paramedic in a busy 911 system and has worked in all em settings from level 1 down to level 4...I...I...me...I...I...me.

This thread isn't about you.

That is all.

 

[Makati2008]

I'm used to working places with volumes less than 5k so that might be a difference in rates and I'm pretty restricted geography wise as well. Also I know a cpl docs that shouldn't be working in the ED and would take a seasoned EM PA vs them without a thought.

 

[cabinbuilder]

.....some fp docs are great in the er. some I wouldn't want to place in that setting, ditto pas and np's but some of us are actually up to the task and do it well..

This is true for any specialty, or ANY job for that matter so to extrapolate for the ER only is just silly. In general there are GREAT docs and there are terrible docs. Life happens.

 

[deleted6669]

This thread isn't about you.

That is all.

I was using myself as an example because I know what I have done and I'm actually pretty typical for senior em pas..
medstar made a blanket statement that any doc is better than any pa in the er. clearly wrong and misinformed..this line of thinking puts new grad fp docs 1 week out of residency staffing an er solo. I've seen it and it's dangerous. I walked into a shift in which I was relieving such a doc and she was working up a young aloc pt. who had been there in the dept for a while and I asked "what was the response to narcan?" and she said" oh, I didn't think to give any" . then she asked me the dose and gave it. pt revived. this is a no brainer and should not ever be missed. this is like not checking a blood sugar in a disoriented diabetic.

 

[deleted6669]

thank you for proving my point.

 

[NOsaintsfan]

medstar made a blanket statement that any doc is better than any pa in the er. clearly wrong and misinformed..this line of thinking puts new grad fp docs 1 week out of residency staffing an er solo.

I'm not sure this is exactly what he meant. He (medstar) did say that he would only hire a FM trained doc to work in his dept. that had at least 2000 hrs of ER time in residency. He also said he didn't hire one of his own residents for that exact reason, not enough ER exposure.

I took his statement to mean that he would take any physician with adequate ER exposure over any MLP.

Maybe I'm wrong.

 

[Medstar911]

I'm not sure this is exactly what he meant. He (medstar) did say that he would only hire a FM trained doc to work in his dept. that had at least 2000 hrs of ER time in residency. He also said he didn't hire one of his own residents for that exact reason, not enough ER exposure.

I took his statement to mean that he would take any physician with adequate ER exposure over any MLP.

Maybe I'm wrong.

Yes. That's what I meant. Thanks for catching that.

 

[EdibleEgg]

I don't see rural EM closing as an option for fm grads closing any time soon. Rural EM is just different. I can't see many EM guys going to locations with hospitalist coverage like Medstar describes. There just aren't that many dual boarded docs out there, and most of them are going to practice in more urban settings where pay is higher. We've had several EM boarded guys come through here over the last couple of years. Only one has stayed for any length of time, and that's because he has family ties to the area.
Who really knows, health care is changing so rapidly.....

 

[deleted6669]

Yes. That's what I meant. Thanks for catching that.

Fair enough. sorry I misinterpreted your post.

 

[styphon]

Lots "turf battle" here, I would guess medical students/residents as they are overly focused on such issues.

In reality, if you can show you had proper procedural experience and are FM trained, even without a fellowship, rural ers WILL hire you. I've done urgent care: where I have done the eye procedures mentioned, and have also been offered an er position at the local rural er.

Don't listen to the people here puffing out their chests, Residents/medical students love these turf battles, but really the hospital administration could give a crap. The only trouble would be getting into er in major city, as they usually stick to em boarded.