EM fellowships

[Andy Kahn]

As mentioned in a previous thread, it does seem that many of the EM fellowships are mainly for a personal interest. I feel that a career opportunity in those subspecialty fields are mainly for those wanting to be a faculty member somewhere. I assume that most residency programs want faculty members in tox, pedi, ems, u/s, etc. to teach the residents, be a consultant for other faculty, produce research on those topics, run a fellowship/section of the ED (poison ctrl, pedi ED, 911,), and to add variety to the department. I guess it may also depend on location of programs for needing faculty in wilderness medicine, hyperbarics, mass gathering, etc.

I like the fact that EM fellows and fellowship trained EPs usually still work shifts in the ED but also can be the "expert" in something related to EM at the same time. This is in contrast to those that do fellowship training after medicine, peds, or surgery who no longer work as a general internist, general pediatrician, or general surgeon. I guess the gastroenterologist, pediatric cardiologist, and cardiothoracic surgeon make a higher salary and no longer primarily treat hypertension, otitis media, or inguinal hernias.

The disadvantage for fellowship trained EPs is that they usually cannot work only in that subspecialty (although I want to continue practicing in the ED in addition to u/s or tox) and the salary may not be that much despite extra training. I am planning on doing a fellowship b/c I would like to go into academics. It seems I will actually be losing money by doing a fellowship since that time (1 or 2 years) in fellowship provides a lower salary than working as an attending or in private practice. With a career in academics, I have heard the pay is substantially less than private practice, but I guess I should do what I will enjoy most.

Below are some of the opportunities (in addition to teaching) I have heard in relation to the various fellowships.

Tox - poison ctrl, environ/chem companies, inpatient consultant
Pedi - pedi ED
Sports med - team physician, ?
EMS - running a city prehospital system
U/S - teaching residents as well as travelling out to teach in the private world (this may decline as EM residencies are required to include more u/s in the curriculum), reviewing u/s done in a private EP group
Informatics - incorporating computers/pda's/etc into the ED to improve pt care
Disaster/mass gathering - covering large events, catastrophes
International - mission work?
Wilderness - natl parks, various areas?
Administration - running an ED, program?
Critical Care - ICU, handing pts in ED when units are full, ?
Hyperbaric - hyperbaric chambers (CO poisoning, burns, diving/undersea)


I would be interested to hear any thoughts anyone might have to add...

Thanks,
-ak

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[southerndoc]

Out of curiosity, does anyone foresee a time where malpractice insurers require or offer discounts to physicians who have completed a fellowship? I'm specifically referring to EMS. Perhaps insurers already discount premiums for its physicians who are EMS fellowship trained.

 

[Jeff698]

Out of curiosity, does anyone foresee a time where malpractice insurers require or offer discounts to physicians who have completed a fellowship? I'm specifically referring to EMS. Perhaps insurers already discount premiums for its physicians who are EMS fellowship trained.

Good question. I'm also very interested in an EMS fellowship (hell, that's the whole reason I'm in medical school). I've spoken with several of my friends who are medical directors and they saw that there suprisingly isn't that large of a premium for being an EMS medical director. If this is consistently true, there probably wouldn't be much point to decreased cost based on fellowship.

I was just speaking with a physician who still practices. He pays for his usual policy which covers him for any patients he personally sees in the field. This isn't a rider, it is part of the base package (I don't know how common this is, though). His department then provides an administrative liability policy to cover his delegated practice.

Andy, should you feel the need to do an EMS fellowship, you're in a good place. Southwestern has one (plus a pretty cool national policy/mass casualty one). In any case, you can definitely put me down for wanting an EMS one.

Take care,
Jeff

 

[Andy Kahn]

Good question. I'm also very interested in an EMS fellowship (hell, that's the whole reason I'm in medical school). I've spoken with several of my friends who are medical directors and they saw that there suprisingly isn't that large of a premium for being an EMS medical director. If this is consistently true, there probably wouldn't be much point to decreased cost based on fellowship.

I was just speaking with a physician who still practices. He pays for his usual policy which covers him for any patients he personally sees in the field. This isn't a rider, it is part of the base package (I don't know how common this is, though). His department then provides an administrative liability policy to cover his delegated practice.

Andy, should you feel the need to do an EMS fellowship, you're in a good place. Southwestern has one (plus a pretty cool national policy/mass casualty one). In any case, you can definitely put me down for wanting an EMS one.

Take care,
Jeff

Jeff, thanks for the post. What are some of the reasons for your interest in EMS? UTSW really likes to mention how the Chair, Dr. Pepe, has a good connections and experience with the nat'l/mass casualty field (GEMSS fellowship is up and running). The PD, Dr. Wainscott, ran the EMS system in El Paso for awhile. Dr. Rinnert is EMS fellowship director at UTSW. Dr. Benitez did his EMS fellowship there and is now on as faculty. Dr. Fowler also is one of the EMS faculty. My wife is more interested in EMS than I am so Dallas may offer an advantage for her. I thought that I would do toxicology, especially after my away rotation there because I really enjoyed tox rounds with Dr. Velez (she has a chapter in the new Tintinalli on Cyanide with Dr. Delaney who I heard worked with Goldfrank at Bellevue). Dr Keyes is the tox fellowship director and he's pretty cool and funny. I am now leaning towards ultrasound which is a fellowship that UTSW does not have, but they have someone doing an ultrasound fellowship right now who will come back to UTSW afterwards.

 

[southerndoc]

Dr. Fowler also is one of the EMS faculty.

That wouldn't be Ray Fowler who used to practice in Macon, Georgia, would it?

 

[Andy Kahn]

Dr. Ray Fowler mentioned that he worked in the suburbs of Atlanta for a long time and now is in academics b/c he wants to work w/ students. He's a great guy and did a great job of teaching while I was there rotating.

-ak

 

[roja]

Andy-

I am planning on doing an U/S fellowship. I think that there are alot of reasons to do a fellowship right now. The majority of ED's dont' have EM U/S trained individuals and are looking for people to come in and set up the U/S division. There is one guy here who is goign into private and is heading up the u/s division for a small private hospital. So, you don't just have to go academic (although this is my plan).

I intend to be RDMS certified before I graduate so that I can spend most of my time during fellowship learning the more beurocratic aspect of EM U/S. I am also really interested in research so.....

 

[Jeff698]

Jeff, thanks for the post. What are some of the reasons for your interest in EMS?.

Howdy Andy!

I've been a paramedic for 16 years which sort of gives me a itty bitty bias towards EMS.

That really is the reason I'm in medical school, though. I was very active in promoting the advancement of EMS (primarily through education) in Texas and felt I could have more of an impact as a physician than as a paramedic. Plus, I'd gotten into education and administration and really missed taking care of patients.

How are you managing the countdown to graduation? Dealing well with all the intellectual stimulation of your final months here at UTMB?

Take care,
Jeff

 

[EMIMG]

Be careful with fellowships in Emergency Medicine. They are not all the same.

Let's take a quick look at some of the fellowships. For instance, Peds EM, Toxicology, Undersea and Hyperbaric Medicine, and Sports Medicine all have subspecialty certification exams. Therefore, there is probably some standardization of the material that is present.

Now, the other fellowships have no certification programs and essentially no standardization. Anyone can open up an EMS or a Wilderness Medicine or a Administrative Fellowship. You just really have to ask a lot of questions and really try to find out what you will get from it. Is there anything beneficial to it? Are you going to be respected during your fellowship and work with your fellowship director, or are you just going to be used for labor and work for your fellowship director? What are your other responsibilities in terms of teaching, clinical duties, etc.

I had the opportunity to research and interview at some of the fellowship programs for one of the fellowships which is not one which you can sit for a subspecialty exam offered by ABEM; however, it is a fellowship which is becoming more and more popular and has undergone a boom with number of spots. I quickly realized that not all of the fellowships are the same. Ask questions, talk with people in the field. Find out who are the leaders in the field. Find out who is during current research, and who is relying on something they may have published years ago.

By doing a fellowship, you are making an investment into your future. Make sure you know with what you are getting involved.

 

[Andy Kahn]

For instance, Peds EM, Toxicology, Undersea and Hyperbaric Medicine, and Sports Medicine all have subspecialty certification exams. Therefore, there is probably some standardization of the material that is present.

I noticed that on FREIDA (http://www.ama-assn.org/vapp/freida/srch/ and then click on "Choose Specialty") that Peds, Tox, and Sports Med are listed as fellowships with (EM) after them. Undersea and Hyperbaric and Tox (again) was listed with a (GPM) designation although I usually hear of hyperbarics mainly as an EM related fellowship. On http://www.acgme.org/adspublic/ under "List of Programs by Specialty," they list Peds, Tox, and Sports under EM and again Tox and Hyperbarics under Gen Prev Med. Sports Med is also mostly listed under Family Med and some under Internal Med. Do most fellowships accept applications from various residency types (EM, IM, FM, etc) or do some only take from their own specialty?

Now, the other fellowships have no certification programs and essentially no standardization. Anyone can open up an EMS or a Wilderness Medicine or a Administrative Fellowship. You just really have to ask a lot of questions and really try to find out what you will get from it.

Very good point. What's the best way to find out which of those fellowships are strong? I guess word of mouth usually gets around. I am curious as to what the next accredited/certified EM fellowships will be...

 

[FoughtFyr]

I am curious as to what the next accredited/certified EM fellowships will be...

On the interview trail I repeatedly heard there was (is) movement afoot with NAEMSP to standardize the EMS fellowships. In fact, more than one EMS director said this incoming class or the next would be the last that could be EMS directors without the fellowship. (Their opinion, not mine). It will be interesting to see if they are right.

- H

 

[EMIMG]

Hyperbarics is obtainable throught both EM and I think Preventitive med
Sports Medicine is available through both FP and EM.
Peds EM is available through Peds and EM
And Tox is via EM but can also get through pharm as well.

In terms of additional things being approved by ABEM for subspecialty, I don't know. I think that with EMS, things vary depending on the region and city you are in. In addition, things like admin will vary with local politics. As for ultrasound, I can't see any standardization in this as many people will go for their RDMS which will "standardize(?)" (term used loosely) people.

In terms of finding out what is a good fellowship....do your research. Get involved with the subspecialty societies or interest groups and find out who the movers and shakers are. As questions. Esepcially if there is a fellowship you do not get into or offered an interview, ask them who has the good fellowships. Most fellowship directors will be completely honest with you and share their opinion about what they know of other fellowship directors.

With that being said, once again, a word of advice...not all fellowships are the same. You will not get the same training at all of them. Clearly, there are some that are superior than others. Also, some focus on different things. For instance, some tox programs may be more involved with environmental toxins and investigating toxins in the workplace whereas others may be more focusing on overdoses, and hospitalized patients. There will be reginoal variations in terms of toxic plants, animals, etc.

Hope this helps.

 

[Jeff698]

In fact, more than one EMS director said this incoming class or the next would be the last that could be EMS directors without the fellowship. (Their opinion, not mine). It will be interesting to see if they are right.

As much as I'd like for that to be true, I can't see that being anything other than wishful thinking. NAEMSP can wish this were the case until they're blue in the face, but when we have oodles and oodles (a precise number, BTW) of 'signature' medical directors who have to be begged to offer their 'services', I can't see requiring fellowships.

Sadly. Maybe some day.

Take care,
Jeff

 

[southerndoc]

As much as I'd like for that to be true, I can't see that being anything other than wishful thinking. NAEMSP can wish this were the case until they're blue in the face, but when we have oodles and oodles (a precise number, BTW) of 'signature' medical directors who have to be begged to offer their 'services', I can't see requiring fellowships.

Sadly. Maybe some day.

Take care,
Jeff

If the state medical societies and state EMS organizations follow NAEMSP recommendations, then they might require services to have medical directors who are fellowship trained.

 

[pman95]

If that's the case....there will be A LOT of EMS services without a medical director.

 

[FoughtFyr]

If that's the case....there will be A LOT of EMS services without a medical director.

Not if they "rolled it out" by grandfathering in all existing EMS PDs.

Just a thought...

- H

 

[FoughtFyr]

As much as I'd like for that to be true, I can't see that being anything other than wishful thinking. NAEMSP can wish this were the case until they're blue in the face, but when we have oodles and oodles (a precise number, BTW) of 'signature' medical directors who have to be begged to offer their 'services', I can't see requiring fellowships.

Sadly. Maybe some day.

Take care,
Jeff

Which is why I said "Their opinion, not mine". It was strange that two otherwise independant programs, widely separated geographically, said nearly the same thing.

- H

 

[SaltySqueegee]

Excellent thread. Thank you to the OP!

 

[Jeff698]

Which is why I said "Their opinion, not mine".

Sorry, didn't mean to imply I was arguing with you. You were fairly clear about it not being your opinion.

From my time getting my butt chewed on as the Texas state training coordinator, I'd love to see an attempt to require a fellowship as long as I wasn't the one who had to implement that requirement.

Actually, Texas is looking at, in the future, requiring medical directors to take an EMS medical directors course. Not quite the same as a fellowship but a good start, IMHO. I've sort of been out of the loop for the past three years (my little medical school hiatus) so I'm not sure of the exact details but this is something that TCEP is working on.

Take care,
Jeff

 

[roja]

We actually just had a former ABEM president come and lecture for our confrence. We discussed some of the 'accredited' fellowships and which ones would/would not have boards to sit for.

For example, someone asked about EMS and he made the point that there would probably never be one. Our EMS director was there and asked why. And the speaker had a valid point, what is there really to test? Much of EMS fellowship is learning the administrative aspects of prehospital care. And this varies not just from city to city but state to state. How do you standardize a test?

Same for Ultrasound. There really isn't enough there for a full blown standardized test. And most good fellowships will require there fellows to become RDMS certified which is the standard among radiologists for ultrasound. (this incidentally, has nothing to do with your HOSPITAL accrediting you to do scans in the ED, but increases the likelihood that you won't have problems.)

I imagine there is enough in tox but havent' done my rotation yet.

 

[Andy Kahn]

Same for Ultrasound. There really isn't enough there for a full blown standardized test. And most good fellowships will require there fellows to become RDMS certified which is the standard among radiologists for ultrasound. (this incidentally, has nothing to do with your HOSPITAL accrediting you to do scans in the ED, but increases the likelihood that you won't have problems.)

I imagine there is enough in tox but havent' done my rotation yet.

Interesting. I guess a board in those fields would be nice to have, but usually the fellowships themselves seem to be enough (for now). I figured there are enough basics in EMS and U/S to be tested on boards despite the regional differences. I do not know much about EMS, but for U/S there seems to be plenty of material to cover in terms of the physics (ugh... but I guess it helps to understand it better), machine controls/buttons (knobology), techniques, views, interpretation, and management (I guess being EM trained should make these questions easier if you know what the scans are: retrobulbar hematoma... lateral canthotomy, pericardial effusion/tamponade... pericardiocentesis, free fluid in Morison's pouch or ruptured AAA... call surgery and bolus/transfuse, non-compressible popliteal vein with abnormal flow... heparin, etc.

I know that tox and pedi EM must have plenty of materials for their boards, but the other 2 current boards (sports med and hyperbarics) I do not know much about so I do not know how much they have to test over, but apparently they have enough.

I was talking to a couple of anesthesiologists the other day and they were surprised when I told them about EM fellowships. Many people don't know there are EM fellowships (but I guess some don't even know there are EM residencies!). I have heard that the more research we put out, the stronger EM will be especially when others start using our literature in their practice. I feel the same way about fellowships. The stronger our subspecialities are, the stronger EM will be, especially if we are consulted for a change. I guess tox may be consulted for inpatients admitted with an exposure or OD, but there will always be inhouse radiology and peds to take care of those patients instead of U/S or Peds EM. I suppose ortho or medicine will take over any Sports Medicine pts. Still a big difference that I like is that the EP does the ultrasound while usually a tech does it for the radiologist. This gives the EP more control over views and to have the pt's right there along with his H&P to help guide the interpretation. The EP can give so pain medicine so that the patient can tolerate a probe being pressed firmly. I guess that makes the RDMS very important. In the post above it was mentioned that radiologists specializing in U/S are RDMS certified also. Do they usually do their own scans or do they have a tech do them?

 

[roja]

I think the point that the speaker was making was that to have a special EM board, you have to test on material that is specific to EM. The RDMS certification includes a physics exam. The physics is not unique to ER ultrasound and thus, no need for an EM board exam. In terms of knobs, this changes from machine to machine. (just look at a sono site and another machine side by side.)

Remember, most radiologist DON"T do ultrasound. If a res wants to become a specialist, they do a 2 year fellowship in ultrasound AFTER they complete thier residency.

 

[Andy Kahn]

I think the point that the speaker was making was that to have a special EM board, you have to test on material that is specific to EM. The RDMS certification includes a physics exam. The physics is not unique to ER ultrasound and thus, no need for an EM board exam. In terms of knobs, this changes from machine to machine. (just look at a sono site and another machine side by side.)

Remember, most radiologist DON"T do ultrasound. If a res wants to become a specialist, they do a 2 year fellowship in ultrasound AFTER they complete thier residency.

Oh, I see what you are saying: Since there is an RDMS exam, then a EM U/S board exam is not necessary. I guess the physics is the same, but the management questions would only be for the physician board questions. I agree that the knobs are different, but the use of certain functions (increasing real estate, modifying the gain when there is shadowing or posterior acoustic enhancement, etc) would be important knowledge to test even if the knobs that control them are different on various machines. I will have to read through Ma/Mateer to see how much material in there would be things that are specific to EPs which the RDMS exam would not cover.

I didn't realize the radiology U/S fellowship is 2 years. Do they still have the techs to do scans even if they have completed their fellowship or do the U/S trained radiologists do their own scans?

Thanks for the info.
-ak

 

[roja]

I think that depends on the radiologists. I am sure some of them do thier own.

The ma book is really good. I have already read it once (yes, call me a geek). However, modifying the gain doesn't really change posterior enhancement. I have found the best resolution is to simply make liver look like liver and then not touch the knobs! Its kind of become my chant. 'LIVER LOOK LIKE LIVER" catchy, no?

 

[FoughtFyr]

We actually just had a former ABEM president come and lecture for our confrence. We discussed some of the 'accredited' fellowships and which ones would/would not have boards to sit for.

For example, someone asked about EMS and he made the point that there would probably never be one. Our EMS director was there and asked why. And the speaker had a valid point, what is there really to test? Much of EMS fellowship is learning the administrative aspects of prehospital care. And this varies not just from city to city but state to state. How do you standardize a test?

After working as a municipal consultant, I feel dead opposite that speaker. My job was to go to various municipalities to evaluate their EMS. Most EMS directors had no idea what alternatives to their systems existed. Few knew about National Registry vs. State Certs. Some did not even know there are DOT guidelines. To say nothing of the different system designs. There was rarely consideration given to the make-up of local fire departments with regard to contracts and how they interplay with EMS. QI/QA, if done at all, was rarely up to a reasonable standard. Most times the EMS director had "inherited" the system and just kept things more or less on the same course. That is the problem with EMS, IMHO. Until we have a group of physicians trained in the different system models and their pros and cons, in government regulations and law, in labor negotiation, and in QI/QA data collection with an emphasis on prehospital providers, it will be dificult to bring about any reasonable reform.

And lots of folks are looking for that reform. I was billed out at greater than $200/hr (no, I didn't make that much, my company did) as a consultant.

- H

 

[roja]

Well, his point wasn't that fellowships shouldn't exist. But the EM certification exam process innately requires that there be enough unique and testable material to come up with a board exam.

It doesn't mean that there shouldn't be a national standard just that there wasn't really a way to create a ABEM board exam.

Just like there isn't in U/S. However, there are standards, and that is the RDMS.

 

[FoughtFyr]

Well, his point wasn't that fellowships shouldn't exist. But the EM certification exam process innately requires that there be enough unique and testable material to come up with a board exam.

It doesn't mean that there shouldn't be a national standard just that there wasn't really a way to create a ABEM board exam.

Just like there isn't in U/S. However, there are standards, and that is the RDMS.

I think there are enough unique and testable things. There is a BS available from U of Maryland in EMS administration. Their coursework could serve as a model.

- H

 

[roja]

I don't know enough about EMS but our director agreed with this. What are you going to test on? Administrative techniqes and requirements vary from state to state. Are you goign to test on APE mgt? this isn't unique to EMS.

Simply because tehre is an undergraduate degree doesn't mean that there is enough objective material to apply across the board.

 

[Whisker Barrel Cortex]

I think the point that the speaker was making was that to have a special EM board, you have to test on material that is specific to EM. The RDMS certification includes a physics exam. The physics is not unique to ER ultrasound and thus, no need for an EM board exam. In terms of knobs, this changes from machine to machine. (just look at a sono site and another machine side by side.)

Remember, most radiologist DON"T do ultrasound. If a res wants to become a specialist, they do a 2 year fellowship in ultrasound AFTER they complete thier residency.

Actually, Roja, pretty much all radiologists are trained in and interpret ultrasound. The majority do not do much scanning once they are done with residency (usually too much other work to be able to do this) except in cases where there is need for clarification. In academics, there is a lot more hands on scanning. Fellowships in ultrasound are very very rare and there are not many radiologists with this sort of training. They are usually only in academic settings. I believe it is a one year fellowship.

We do 4 months of ultrasound in reisdency plus see plenty of them on call. Some hospitals the resident does all after hours ultrasound. At ours its only after midnight that the tech is not available.

 

[FoughtFyr]

I don't know enough about EMS but our director agreed with this. What are you going to test on? Administrative techniqes and requirements vary from state to state. Are you goign to test on APE mgt? this isn't unique to EMS.

Simply because tehre is an undergraduate degree doesn't mean that there is enough objective material to apply across the board.

The fact that they vary state to state and location to location would be the basis of the test. Why shouldn't an EMS director be aware of all the different system designs, the pros and cons of each, methods for change etc. Saying that variation creates a lack of testability is, IMHO, the problem. An EMS director should be able to describe, maintain, and run any EMS system anywhere. They should be able to assess the system, adapt that system as needed for change, and re-engineer whatever is necessary. There should be a solid, base core of knowledge on EMS design. It is not that there is an undergrad degree in EMS, it is that there is an undergrad degree, Master's degrees, and an industry of consultants. These folks end up being the experts in EMS that in my opinion EPs should be.

- H