em fellowships

[ronni]

I'd love to hear opinions from all about the pros and cons of doing a fellowship. I'm on the fence.

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[Stitch]

I'd love to hear opinions from all about the pros and cons of doing a fellowship. I'm on the fence.

Umm...which one?

 

[ronni]

something that would probably involve an mph, even if it's not one of the recognized few (ultrasound, critical, sports, tox, etc.) probably would not change practice, but maybe necessary for practice in academic environment? thoughts???

 

[anonymousEM]

my thoughts are that fellowship is at least 1 year if not two or more of your life after residency. With it comes the opportunity cost of not making an attending salary. I would strongly consider why you'd want to do a particular fellowship rather than "any" fellowship and decide whether the costs and benefits weigh out for you. For me--I chose an international fellowship but I don't think that one who would've done "any" fellowship would've been happy in my program...

 

[docB]

something that would probably involve an mph, even if it's not one of the recognized few (ultrasound, critical, sports, tox, etc.) probably would not change practice, but maybe necessary for practice in academic environment? thoughts???

If you're really looking to use a fellowship to get a leg up in the academic world it really needs to be in one of the recognized few. An MPH by itself might help but that would depend more on what you do with it. Just getting an MPH and adding letters won't help near as much as developing a real area of interest and becoming an expert in it through research. If you go that route you're probably looking at even more time in limbo while you do that course work and research.

My impression is that if you have a real area of interest like that and you'll be fulfilled if you sacrifice $$$ but get to pursue that interest go that route. If you just want to be a fellowship trained academic EP then try for one of the recognized fellowships.

Just to stress you out more if you're gonna do something like this now is the time. It would be really hard to go work for a few years then go back. Marriage, kids, mortgage, etc. build up and create a lot of inertia to overcome if you want to make drastic changes in direction down the road.

Also note that I am neither fellowship trained nor academic so this advice and a Medicaid card will get you 4 mg of Dilaudid IM.

 

[Powder]

I read your post and I can steal someones medicaid card ... so where can I pick up the Dilaudid?

 

[ronni]

just to reply, it's not ANY fellowship that I'm interested in-it's just that it would ideally be a combination of an environmental/toxicology/mph thing

Did doing your fellowship change your practice

 

[DeadCactus]

Maybe I'm alone, but I really think you need to take 15 minutes and figure out what it is you're trying to learn and then phrase it in the form of a specific question...

 

[ronni]

ok-is anyone sorry that they DIDN'T do a fellowship? and for those that did do one, are you using your specialization in your work?

 

[BADMD]

just to reply, it's not ANY fellowship that I'm interested in-it's just that it would ideally be a combination of an environmental/toxicology/mph thing

Did doing your fellowship change your practice

You need to figure out what you want out of a fellowship. How will this change what you are doing in the future? You are speaking in very nebulous terms and you need to nail down what you want and what you want to achieve.

Fellowships suck. They are a lot of hours. While some pay more than others, you will make more, working fewer hours if you just work in the ED. Thus it is critical to have a vision and goal. You need something that will keep you going beside "Hey, this stuff is kind of cool." That isn't going to cut it 6 months in when you are awake at 3 am doing something stupid for the fellowship. I think this is what most people are responding to. Doing a fellowship because you aren't sure what else to do isn't a really good idea.

As for the nuts and bolts, Toxicology does have a significant environmental and occupational medicine component. I'm not really sure if that is what you are looking for. Most Tox programs aren't going to have an MPH. Many of the unrecognized fellowships include an MPH as you can't achieve board certification in them. The MPH is so that you come out with something to show for your work. MPHs are of limited utility, but may help if you want to be an academic. As a note, Ultrasound is not an ACGME approved fellowship.

 

[ronni]

thanx-i'll do some serious sole searching

 

[ronni]

thanx good advice

 

[iso]

note on BADMD's comment: I'm not so sure about fellowship sucking and involving a lot of hours (but I'm speaking as a person who's applying to a fellowship right now). I think it would be good to look at specific fellowships that you are interested in geographically and curriculum-wise. You can do this on the EMRA website using the EMRA Match database, though it's not very complete or well-organized.

At my institution, our fellows work 500 annual clinical hours for PGY4 pay (we're a 3 year program). That comes out to like 2 shifts a week. For my fellowship, you then have about 3 hours of lecture per week and maybe 2 or 3 administrative meetings. It's going to be an absolute walk in the park, and perfect for me since I don't really feel like working hard next year, and I have a year to kill waiting for my husband to get out of his residency program. As a bonus, my program automatically offers a certain amount of moonlighting each month, and if you take those shifts, you increase your pay to $106,000 annually. It's nowhere near what you'd be making as an attending, but it's one year, you're taking it easy, and you get something worthwhile to put on your CV if you would like to work as an academic (or if you just want to have some sort of niche area of interest). I'm just happy to be able to continue working at a place that I love, doing something I enjoy, and then being able to pick up and move across the country when I need to a year from graduation.

 

[dlung]

just to reply, it's not ANY fellowship that I'm interested in-it's just that it would ideally be a combination of an environmental/toxicology/mph thing

Did doing your fellowship change your practice

As a current fellow who cries in a fetal position when he thinks about his former classmates making 6 times his salary, my advice is what my attendings told me--do it sooner than later. The more wealth, toys, and square feet you acquire, the harder it is to continue/go back to a residency lifestyle.

Also, I'll just iterate BADMD's comment: the fellowship has to add value (ie $$$, skill set, career path, protected time) to your career. I'm doing it because it gives me a skill/knowledge set few other people have and makes me more marketable in tough job markets, and gives me a way of getting protected time later (research and non-ED work).

If you really wanted to do all of the above, it's typically a three-year commitment a the few places where you can do it, like UCSF/UC Berkeley.

 

[uncwalley]

I too will reiterate that fellowship does not suck, but it is surprisingly more of a time commitment than I went in thinking it would be. I work 2.5 clinical shifts a week (which justifies the pay) and another "20" hours a week doing fellowship related things. I'm doing an ultrasound fellowship, so that is where my time goes. "20" hours is usually more than that, but a lot of that is at home, and I make my own schedule for that time for the most part.
The advantages for me have been many: the opportunity to further my skills with US, the opportunity to teach, and a foot in the door for future academic jobs. Sure, my former classmates are making 2-3 times what I make, but I just finished 3 years living on a resident's salary and the 4 years before that making no money, so I'm used to living modestly. It's only one year, so I can't complain too much.

 

[DartosDO]

As a note, Ultrasound is not an ACGME approved fellowship.

Is the skill set alone worth an extra year of poor pay? Essentially, the fellowship costs you at least $100,000. Would being in a residency program that really pushes sono be the equivalent since you have no certification?

 

[uncwalley]

Worth is a relative term. For me, I think it is definitely worth it, but being able to say I'm fellowship trained won't ever get my $100,000 back. I've had interview offers at the places I want to work next year, doing what I want to do. Without the fellowship, my pickings would have been more slim.
Your second question depends on you. If a resident just really wants to get good at ultrasound but doesn't want to make it his/her niche and go into the world of academia or become the US director at a larger community group, then a fellowship is probably not necessary. Those who are motivated can learn ultrasound with enough drive to put in the hands-on time it takes. However, it takes a lot more than just using the ultrasound once or twice a shift. Even the programs where residents are pushed to learn ultrasound have a lot of residents who just acquire a few adequate images for review so they can fulfill requirements and move on without learning how to make it a part of their practice.

 

[BADMD]

Is the skill set alone worth an extra year of poor pay? Essentially, the fellowship costs you at least $100,000. Would being in a residency program that really pushes sono be the equivalent since you have no certification?

It depends on what you want to do. If you want to be good at doing ultrasounds, there are other ways to do it. If you want to teach ultrasound, develop an ultrasound program for an ED/residency, do ultrasound research, or something that goes beyond simply driving the machine and interpreting the scan, then the fellowship may be worthwhile. There is going to be a subset of people who just want to be super good at doing ultrasound and are happy to have a year of protected time to do it. Fellowships in anything are going to worth it to someone.

The real key is making sure that why you want to do fellowship matches the reality of fellowship. This is highly individualized, but requires really looking deep into what you expect to get and can the fellowship really deliver that.

 

[DartosDO]

Perhaps a pre-mature question for U/S, but is a 4th yr sono rotation worth doing? Will I actually make use of my time, or will I basically just shadow for 4 weeks? I suppose I could use it as an audition if nothing else is available, but I would hate to spend one of the "good" months watching a screen and not learning much/ not showcasing myself.

 

[uncwalley]

It depends on the rotation. If it is a radiology department US rotation, you will sit in a chair and watch. If it is an EM US rotation, I'm sure it will depend on the place. Most will have you doing a lot of scans by yourself as well as with faculty and fellows. In my mind, it is a valuable month whether you do it during the "good" months or later in the year. Either way, you come into residency with more US experience than most, and if you put a decent amount of effort into it, you may become pretty good with the US and have a huge leg up on your colleagues.

 

[deleted65604]

I don't see the point of fellowships. Classically, fellowships teach you a skill that gives you an advantage in caring for a subset of patients that other doctors can't take care of. This is usually driven by market forces which compensate the physician for their additional training.

EM fellowships in Ultrasound claim they will revolutionize ER, improving patient care and increasing ER revenue. The reality is that they concentrate on teaching non-emergent ultrasounds that are time consuming. Individuals (that I know) do US fellowships with the hope that they will have to do fewer clinical shifts and get paid more. While this job, on occasion, does exist, I don't think they are advancing the field of ER in a positive direction.

The Holy Grail of US is that ER docs will be able to bill for all ultrasounds done in the ER, bipassing US techs, and maximizing revenue. In reality, the increase in ER revenue is not reflected in the average ER doctor salary in that group. The money goes to pay the ER doctor running the US program, in addition to maintaining the computer equipment, US equipment and ultrasound databases in addition to the massive amount of time and money devoted to quality control, which is necessary to justify equivalent billing.

Individual departments shoulder the responsibility of training, quality control, documentation, and medico-legal responsibility formerly burdening radiology departments. Your group ends up paying someone for non-clinical hours and spending massive amounts of money on equipment and non-clinical staff to maintain the US database.

I'm glad there are toxicologists that love toxicology so much that they are willing to take a pay-cut, work far more hours, be on call at all hours of the night on a frequent basis, be forced to do produce tons of research, run follow-up toxicology office hours, and in general, have a job that is, in many ways, the antithesis of the typical ER job. I have been working for 2 years as an attending, and I have never had a patient that would have benefited from the additional knowledge unique to a toxicologist, that isn't available quickly on MDconsult, and without the irritation of SPI nurses pestering you every 4 hours.

ER medicine is specialized enough. Outside of an academic setting, fellowships will get you nowhere. ER fellowships will not get you more money, helpful knowledge, or make you a better doctor. You will not help a specific subset of patients that otherwise wouldn't be served without your fellowship.

 

[Hamhock]

I don’t see the point of fellowships. Classically, fellowships teach you a skill that gives you an advantage in caring for a subset of patients that other doctors can’t take care of.

ER fellowships will not get you more money, helpful knowledge, or make you a better doctor. You will not help a specific subset of patients that otherwise wouldn’t be served without your fellowship.

Critical care and Peds EM are obvious exceptions, but I am guessing you were thinking more about ultrasound and tox.

On the other hand, I have certainly seen cases where both ultrasound- and tox-trained EM docs have been able to "help a specific subset of patients that otherwise woundn't be served with {edit} fellowship"-training. And I think your post implies a drastic underestimation of the impact of modern EM ultrasound on daily practice.

However, I do agree that the trade-off for the occasional patient vs. the time and money that is put into ultrasound or tox fellowships may be unbalanced when viewed from a PP perspective. And if one is considering primarily personal of group finances, Peds EM and CCM may not be wise...but both of these clearly, on a nearly daily basis, give "an advantage in caring for a subset of patients that other doctors can’t take care of" nearly as well.

HH

 

[deleted65604]

What problems can a peds EM doctor take care of in the ER that a non-fellowship trained ER doctor can't?

If you have an ultrasound fellowship under your belt, what patient can you take care of that a non-fellowship trained doctor can't?

If you have an ICU fellowship, what patient in the ER can you take care of that a non-ICU trained doctor can't?

 

[BADMD]

I have been working for 2 years as an attending, and I have never had a patient that would have benefited from the additional knowledge unique to a toxicologist, that isn't available quickly on MDconsult,

And FP and IM can do EM just as well as an EP. All they need are some books and a few online resources.

Seriously, my partners and I get multiple calls, daily, from EPs looking for help. Unless your sick patients are getting immediate dispositions, you are probably assuming a bit much. Not to mention that I have now been involved in 3 cases where patients could have been harmed due to errors in online, subscription based medical resources. I would use them with hesitation.

 

[Axehandler]

Well, here is a different thought. I spent 7 years as an attending in the ED. Nights, weekends, holidays, swing shifts, tired all the time, missing important milestones for my children and family. Living with the crap you have to take as the contracted group from administrators. Kissing butts of nurses, patients and idiot referring docs to massage the contract. Living in the fish bowl, dealing with the constant monday morning quarterbacking. EM makes you a one trick pony. You can't just do more clinic. You can't make the new guy do the nights or weekends. You can do urgent care--same crappy evening hours for less money. This is not ever going away. Last year I started the hospice and palliative medicine fellowship. I gave up partnership in a group, took my severance and have never been happier. I am now starting my own outpatient palliative and pain practice. My choice of who I will see, my rules for payment, scheduling, phone calls-my terms, my hours. This is not an option without further training. EM has no escape plan. At some point you will want out.

 

[deleted65604]

Here is the true problem with fellowships. If you want to work in an ER, you should train in an ER. If you absolutely want to work in a tox center and can't see any other place where you'll be happy, go do a tox fellowship. If you want to work in a pediatric ER and can't see any other place where you'll be happy, great, go do a fellowship.

Some fellowships don't achieve the goal that their applicants have, however. If you do a wilderness medicine fellowship, you aren't going to be a wilderness medicine doctor, if there is such a thing. If you love ultrasound so much that you can't see doing anything else, go to rad. tech school and then train to be an ultrasound tech for 2 years.

The problem is that some medical students go into ER, thinking, I kind of like ER, but I think I'd burn out, I'll get a hobby that will land me a cush job. This isn't like internal medicine, where you know you hate internal medicine, but must jump through the hoops of the residency to land a GI gig. You still have to work in the ER for your primary job, and every hour spent on ultrasound, is an hour away from peds, ophthalmology, general suurgery, etc.

 

[Moonglow]

I spent 7 years as an attending in the ED. Nights, weekends, holidays, swing shifts, tired all the time, missing important milestones for my children and family.

... my own outpatient palliative and pain practice. My choice of who I will see, my rules for payment, scheduling, phone calls-my terms, my hours. This is not an option without further training. EM has no escape plan. At some point you will want out.

Many of the big academic EM residencies are now 4-year programs, with a built in year of sub-specialty training. I really liked the 1990's, old school 5-year combined programs (3-year IM residency and 2-year EM)... BC eligible for both specialties.

 

[RxnMan]

...I really liked the 1990's, old school 5-year combined programs (3-year IM residency and 2-year EM)... BC eligible for both specialties.

These programs started in the 90's, but it isn't like they went away - there's still some 12 programs. But this was never a common residency structure in EM.

Many of the big academic EM residencies are now 4-year programs, with a built in year of sub-specialty training...

Two are - BIDMC and JHU. And BIDMC's extra year is optional.

Sound's like "Many" = JHU

 

[Pinner Doc]

What about the utility of a sports med fellowship? For one year, you get some extra skills in the management of sports med/ortho injuries in the ED (some would argue approaching 20% of patients in the community), and you have the "escape plan" of a gig in sports med clinic to escape the grind of the ED. To me, it makes sense.

 

[Moonglow]

RxnMan,

Off the top of my head: BID, Hopkins, Yale/Bridgeport, Northwestern, UPenn, Michigan, Michigan State, Cincinnati, Ohio/Doctors, USF-GH, USF Fresno, NYU/Bellevue, Brooklyn Hospital Center, and Albert Einstein offer 4-year EM residencies, - you can do your own research for the others.

And an example of the 5-year (3-IM, 2-EM) program:

http://www.umm.edu/imres/im_em.htm

 

[RxnMan]

...Off the top of my head: BID, Hopkins, Yale/Bridgeport, Northwestern, UPenn, Michigan, Michigan State, Cincinnati, Ohio/Doctors, USF-GH, USF Fresno, NYU/Bellevue, Brooklyn Hospital Center, and Albert Einstein offer 4-year EM residencies, - you can do your own research for the others...

Yes, those are all four year programs, but only Hopkins has a built in year of sub specialty training.

Perhaps you should do your own research too.

...And an example of the 5-year (3-IM, 2-EM) program:...

A link to a program (one of the 12 I mentioned) doesn't support anything you said about EM/IM residencies. Though it does disprove the bolded portion, as the link clearly states residents spend an equal 30 months training in both specialties.

 

[Moonglow]

Points:

Although curriculum will vary, four-year EM residencies will be the norm for many large academic programs. A five-year program (3-IM/2-EM) allows for double boarding, and offers clinical options for those who want clinical options.

 

[deleted65604]

Not to mention that I have now been involved in 3 cases where patients could have been harmed due to errors in online, subscription based medical resources. I would use them with hesitation.

Could you give me specifics of those 3 incidents where online resources have been wrong, and the ER doctor didn't know the answer and you did. Please cite the resources.

Again, I give the challenge of telling me of a certain patient where your fellowship gave you the training in the ER in dealing with a particular patient that otherwise would have died.

 

[docB]

What about the utility of a sports med fellowship? For one year, you get some extra skills in the management of sports med/ortho injuries in the ED (some would argue approaching 20% of patients in the community), and you have the "escape plan" of a gig in sports med clinic to escape the grind of the ED. To me, it makes sense.

Making a living as a sports me doc is really tough. I don't think it's a very good escape plan. All the sports med guys I know make their nut by doing primary care or ortho. I support my sports med habit by doing EM. I suppose if you were ready to retire and didn't need much money, maybe.

 

[BADMD]

Could you give me specifics of those 3 incidents where online resources have been wrong, and the ER doctor didn't know the answer and you did. Please cite the resources.

All three were in Uptodate. Two had to do with calcium channel blocker toxicity and one had to do with lithium. One had the wrong dosing and the other recommended sodium polystyrene exchange resin. Then there was the famous case where IV colchicine was recommended for pericarditis. I wasn't involved in that one, thank heavens.

Again, I give the challenge of telling me of a certain patient where your fellowship gave you the training in the ER in dealing with a particular patient that otherwise would have died.

Any of the cardiovascular drugs intoxications; I have had or consulted on most of them at this point. Appropriate diagnosis and treatment of a possible toxic alcohol. Hell, treatment of antimuscaric intoxication. Then there are the atypical acetaminophen poisoned patients whom we see more frequently than I like to think about.

Not all of these patients would have died. However for many of them, I can definitively say that I prevent morbidity, such as extra days in the hospital, unnecessary procedures, unnecessary testing, unnecessary medications and unnecessary cost. For a few, they may have died had I not seen the patient.

Keep in mind, my job extends beyond the ED. Limiting the utility of a fellowship trained EP to what they personally see ED is really belittling what many of us do and frankly, is a strawman when it comes to rejecting ED related fellowships. That isn't why the fellowships exist and that isn't how most of us (and I mean all fellowship trained EP) actually use our training. You don't want to do floor consults? Ok. But saying that the entire fellowship is worthless because YOU don't want to leave the ED is actually puzzling.

While you may be awesome at this, I can tell you that I talk to enough board certified EPs who aren't and want help. Not to mention that a fair amount of what you learned (such as with organophosphates, as an example) aren't quite right and there is far more too it. Most of the time, you can follow what Uptodate/MDconsult/5MinuteConsult says and your patient will live. You can do the same thing with chest pain too. But don't think you have treated them optimally and for some of them, they will need more than what a distillation can provide.

For the same reason you would call a cardiologist to help treat a difficult arrhythmia, you call me for help with difficult to treat intoxicated patients.

 

[deleted65604]

I'm actually glad that there are poison control centers. I happen to believe that a tox fellowship is the one legitimate fellowship in ER. My comments were directed to you because I thought you were an ICU fellow or US fellow or something. I'm glad that I had toxicologists sitting at most of my lectures in medical school. I would grant that in serious overdose patients (not the typical lame borderline cry for help), I would want a toxicologist on the phone.

However, I think a lot of people start fellowships with the idea that they are going to get a job which simply does not exist (or at least, is not lucrative, and is not going to make them more attractive of an applicant to the average ER).

Now, if you want to be one of the tiny proportion of people that go into academics, then a fellowship could help you in that endeavor to facilitate your "niche". I think that there are a host of fellowships that are useless in academics as well, but I've already ranted on those numoerous times in the past.

Outside of academics, I think fellowships (all of them) are completely pointless. For example, had I done a toxicology fellowship, there is not a single patient that I would have managed better in the past 2 years. Will there be in the future? Sure, but wasting 2 years of my time on a tox fellowship while planning on going into community medicine is laughable.

Is there a place for ultrasound training? Absolutely. Is there a place for disaster medicine? Is there a place for ICU training? Is there a place for administrative training? Yes, yes, and yes. I just don't think (with the exception of tox) that a year or two devoted to those topics is going to make you a better attending in the ER. I think that the focus of ER training should be cranking out good quality ER doctors, not producing pseudo-physicians running around the world chasing their hobbies.

 

[pseudoknot]

What about EMS fellowships? The job of EMS medical director does indeed exist, and many seem to feel that if you are going to be a full time medical director for a large system, you ought to have a bit of specialized training.

 

[deleted65604]

What knowledge is unique and vital to an EMS director? Not much. The main duty is to teach paramedics, oversee problems and help conduct meetings. The best EMS director is a good ER doctor. If I were a paramedic, I'd rather have a seasoned ER doctor than a green (right out of residency) doctor with a meaningless fellowship under their belt.

Granted, you might gain some knowledge by attending extra meetings, as there is a true art to conducting quality meetings. I've been to meetings where I thought I was in a Dilbert cartoon, and I've been to meetings that actually accomplished something. Most have been the former. I think that you've got to prepare for meetings with an agenda, sending out that agenda ahead of time to the participants, asking for additional items of business, and getting people thinking of solutions to problems even before you are in the meetings.

 

[deleted65604]

I think perusal of some of the posts below will give you some more pros and cons:

Thread on sports medicine fellowships:

http://forums.studentdoctor.net/showthread.php?t=617566

Thread on tactical medicine:

http://forums.studentdoctor.net/showthread.php?t=691146

Thread on wilderness medicine:

http://forums.studentdoctor.net/showthread.php?t=601667

Thread on ultrasound in Er:

http://forums.studentdoctor.net/showthread.php?t=577944

Thread on International Medicine (a must read)

http://forums.studentdoctor.net/showthread.php?t=514318

 

[docB]

What about EMS fellowships? The job of EMS medical director does indeed exist, and many seem to feel that if you are going to be a full time medical director for a large system, you ought to have a bit of specialized training.

I don't know. I think the main thing that an EMS fellowship gives you is networking and some time to get familiar with the literature. You can obviously do it without. I'm not putting it down. I strongly considered doing one. The fact is that you'll never be a toxicologist without doing a fellowship but you can be a medical director without doing one. 20 years from now who knows.

 

[pseudoknot]

I don't know. I think the main thing that an EMS fellowship gives you is networking and some time to get familiar with the literature. You can obviously do it without. I'm not putting it down. I strongly considered doing one. The fact is that you'll never be a toxicologist without doing a fellowship but you can be a medical director without doing one. 20 years from now who knows.

Interesting. It's certainly something I will have to look into more in the future. I had heard speculation that if it became one of the boarded subspecialties, it would become more of a requirement. I've also heard that having political connections is more important than anything else for getting the big jobs in EMS, and a friend of mine thinks the fellowship is a waste of time for those with significant prehospital experience before residency.

 

[boo2]

What about the utility of a sports med fellowship? For one year, you get some extra skills in the management of sports med/ortho injuries in the ED (some would argue approaching 20% of patients in the community), and you have the "escape plan" of a gig in sports med clinic to escape the grind of the ED. To me, it makes sense.

That was part of my rationale for doing a Sports Fellowship-to have options. You will have to swallow that there will likely be a large pay discrepancy with this "escape plan". Of course its all location dependent, and there are sweet gigs out there, but the few salaries I have heard quoted are more like earning a little more than an FP doc. For instance if an average EM doc starts out making 200k, I would say Sports Docs may start out at 130-150k. You could make more in a busy clinic- ortho(maybe near 200K with bonus) or primary care sports with high volume and high procedure numbers busting your tail. The key is if you get on a partnership track with a piece of the xray, PT pie as well. Again these numbers are gross estimates and vary greatly on the location.
After doing clinic work, even when it is busy with 20-30pts in half day, it is nothing compared to the chaos and stress of the ED. I have come to more fully appreciate why we are decently compensated in the EM.

Also in terms of using Sports fellowship knowledge in the ED- it helps a little in terms of feeling confident examining someone with MSK issues( a step beyond broke or not broke) or counseling patients on what to expect, but you learn the essentials in an EM residency.

 

[Dwindlin]

Outside of academics, I think fellowships (all of them) are completely pointless. For example, had I done a toxicology fellowship, there is not a single patient that I would have managed better in the past 2 years. Will there be in the future? Sure, but wasting 2 years of my time on a tox fellowship while planning on going into community medicine is laughable.

Just out curiosity, what are your opinions on the CC fellowships, if one has the intent of splitting time?

 

[deleted65604]

I think that having an ICU fellowship trained doctor who is an attending in the ER would be cool in the setting of an ER residency. They are going to have insights that others might not have.

I'm not sure about the utility of additional training if you simply want to practice in the community.

If I have a REALLY sick patient in the ER, I'm going to force the ICU doc to come down and help manage THEIR patient. I'm not going to mcro manage ICU patients for 3 hours in the ER. I can't. If the nurse asks me as I walk by what to do with a now crashing ICU patient that is getting admitted to their service, I'll briefly trouble shoot ("Go up on the dopamine. Don't you have orders for that?") and I'm going to call the ICU doctor to let them know the change I made, what additional orders they have, and if they would please come assess their patient again.

It's not that I don't know how to manage ICU patients (I spent 3 years training in EMERGENCY Medicine), it's that there is such a great variety in strategies, pressor choices, patient presentations, that whatever I say is going to be second guessed by the ICU doc and criticized roundly. I want them involved in an ICU patient stuck in the ER, for the sake of good patient care, continuity of care, medicolegal liability, etc.

I also have a concern about doing adult ICU for 2 years, and not seeing OB-Gyn, Ophtho, peds, ortho, trauma, etc. I remember how hesitant/nervous/paranoid/indecisive I was coming out of residency (I tried not to let my patients see that). I can't imagine training in an ICU for two years, then being forced to return to topics/patients that I haven't seen in 2 years, not having a firm confidence in my abilities to manage those patients to begin with. How about the logistics of keeping two different board certifications up to date?

Now, I know people, that I highly respect, who want to work in both settings, ICU and ER. I'm sure they'll pull it off. However, this seems like a scheduling nightmare, to tell an ER that you'll only be available to work 2 weeks out of each month, and to tell an ICU that you'll only be available to work when you aren't working in the ER. It is amazing how frequent you have to switch around your schedule to help out colleagues, and I'm not sure you'll be doing a department a favor with spotty availability.

My belief is that you need to decide what environment that you enjoy most (come on, there are dozens of clinical settings to chose from) and to get maximum amount of exposure to that area, be it ICU, ER, or an office setting. If you don't enjoy working in the ER more than any other place, for the love of yourself, don't do an ER residency. If you want to do ICU through an ER residency (much more of an uphill battle through ER residency than through internal medicine), I think that is reasonable.

 

[deleted65604]

ER doctors would also have a different (more surgically based) subset of knowledge and training compared to competing internal medicine applicants to a critical care fellowship.

ER residents train in OB-Gyn, trauma, neurosurgery, etc., (more surgically oriented subspecialties). IM residents are doing infectious disease, heme-onc, neurology, rheumatology, pulmonology, etc. IM residents spend the vast majority of their time in residency learning and training for an in-patient environment, not to mention doing more medical ICU rotations. Could an ER resident have a steeper learning curve in their initial critical care training as most of the ICU/ subspecialty training they recieve is not geared as much toward medical ICU patients?

Having never completed an ICU fellowship, and having never practiced in an ICU, I would defer to the opinion of some of the attendings on this board who have.

 

[deleted65604]

KGunner1?

 

[deleted65604]

Emergiq?

 

[mvalento]

the decision to pursue a fellowship ultimately is a personal one based on your projected career satisfaction. i'm a tox fellow and am extremely happy that i made this decision.

yeah, most of my residency colleagues are making more money than i am (although, with moonlighting, the difference isn't as severe as attending vs. resident). there's no question that i could be making more with a clinical job. i also went to a 4 year residency, another '$200,000 mistake', as many call it. it's funny how this never is mentioned for the large number of people who take time off between college and med school. your career takes unexpected turns and sometimes you end up spending 6 years (4 year residency + fellowship) to do the 'same' job as someone else who had only 3 years of training. what matters is if you are happy with your career. money is only one part of that happiness (a significant part, true).

i do have to take call, although there is a definite gratification to answering that pager when you know you are calling to provide expertise in your field. the teaching opportunities are fantastic, if you are into that kind of thing (our fellows are constantly being asked to lecture to EM, peds, IM, and occ med residencies and some private attending groups). as it happens, i am into that kind of thing.

not every academic insitution will demand publication output as a requirement for continued employment. i will agree that this is true at some places. obviously, research (especially dollars) are good for any adademic center. there are forces at play that sometimes aren't apparent, e.g. the department chair's attitude towards a particular specialty. we are fortunate at our center to have a VERY supportive department chair. none of my attendings complain that they are being forced to publish...and, indeed, sometimes research can be rewarding. you have to be interested in the project- but that's why you pursued a fellowship!

many toxicologists do not have private office hours. in fact, they are the minority. it certainly is not a requirement of the practice.

it's nice to have a niche that might provide a career benefit in the future (clinical shift buydown, posion center directorship, perhaps more competitive for academic jobs). i'm not counting on it- again, you never know what jobs will be available or where your career will bring you! some of my residency colleagues who took academic/community positions are already thinking about switching jobs.

ultimately i knew that i wouldn't be satisfied with a career that consisted solely of clinical emergency medicine. i had a string desire to become an expert in a field and i loved my tox rotation as a resident. i'm extremely happy to be a fellow, but it's not the right decision for every EM physician. i don't mean to paint a universally sunny/positive picture about fellowships. there ARE downsides, as have been elucidated earlier. each EM resident has to critically project their career satisfaction with or without additional training.

 

[KGUNNER1]

I think that having an ICU fellowship trained doctor who is an attending in the ER would be cool in the setting of an ER residency. They are going to have insights that others might not have.

I'm not sure about the utility of additional training if you simply want to practice in the community.

If I have a REALLY sick patient in the ER, I'm going to force the ICU doc to come down and help manage THEIR patient. I'm not going to mcro manage ICU patients for 3 hours in the ER. I can't. If the nurse asks me as I walk by what to do with a now crashing ICU patient that is getting admitted to their service, I'll briefly trouble shoot ("Go up on the dopamine. Don't you have orders for that?") and I'm going to call the ICU doctor to let them know the change I made, what additional orders they have, and if they would please come assess their patient again.

It's not that I don't know how to manage ICU patients (I spent 3 years training in EMERGENCY Medicine), it's that there is such a great variety in strategies, pressor choices, patient presentations, that whatever I say is going to be second guessed by the ICU doc and criticized roundly. I want them involved in an ICU patient stuck in the ER, for the sake of good patient care, continuity of care, medicolegal liability, etc.

I also have a concern about doing adult ICU for 2 years, and not seeing OB-Gyn, Ophtho, peds, ortho, trauma, etc. I remember how hesitant/nervous/paranoid/indecisive I was coming out of residency (I tried not to let my patients see that). I can't imagine training in an ICU for two years, then being forced to return to topics/patients that I haven't seen in 2 years, not having a firm confidence in my abilities to manage those patients to begin with. How about the logistics of keeping two different board certifications up to date?

Now, I know people, that I highly respect, who want to work in both settings, ICU and ER. I'm sure they'll pull it off. However, this seems like a scheduling nightmare, to tell an ER that you'll only be available to work 2 weeks out of each month, and to tell an ICU that you'll only be available to work when you aren't working in the ER. It is amazing how frequent you have to switch around your schedule to help out colleagues, and I'm not sure you'll be doing a department a favor with spotty availability.

My belief is that you need to decide what environment that you enjoy most (come on, there are dozens of clinical settings to chose from) and to get maximum amount of exposure to that area, be it ICU, ER, or an office setting. If you don't enjoy working in the ER more than any other place, for the love of yourself, don't do an ER residency. If you want to do ICU through an ER residency (much more of an uphill battle through ER residency than through internal medicine), I think that is reasonable.

These are some legitimate points Jarabacoa. I have always gravitated towards the critically ill patients in the ED, but during a shift, I may only see one or two. There is a lot more to EM than critical care, as you know.

I think any fellowship will help you and the group, if you truly enjoy it, even in the community. However I tend to agree that you'll probably get more mileage in an academic setting or one of those unique private mega-hospitals that have limited residencies.

I have a couple of friends, with both EM and CCM training, who are in private practice. They really don't practice EM any differently. Their ICU practice allows them some very nice variability and unique opportunities since they have both perspectives (some are unit directors). This variability is what some of us find appealing.

The boarding/credentialing issue will always be an issue until the ABEM/ABIM agreement comes through, but smaller communities are hurting so bad for good EM docs AND good critical care docs, that a little extra effort explaining the politics usually pays off.

The scheduling isn't as bad as you might think. Many critical care groups are using shifts similar to EM. Losing your skills during fellowship is always a concern for every fellow. But I can tell you, about the only thing you lose is your efficiency the first few months back in the saddle. I think it would be similar to moving to a new hospital and having to learn a new system. It comes back rather quickly.

As far as management, I agree with you for the most part. Most well trained EM docs are good at the big obvious things in CC. This is what we do. The fine details and the amount of time they take is what really separates the two specialties. I agree, you just can't shut the ED down while you spend 90 min exclusively with one patient, then only see 1 pt. extra an hour while you are working on the details of that critically ill patient. The nurses also start to wig out because they are spending too much time with one patient, etc... They really are logistical nightmares, even for those of us who do both. The next thing you know the waiting room is overflowing and if you happen to work for some groups, you are handing out free steak dinners or movie passes to all those patients that had to wait more than 30 min to see a doc!!

I guess the short answer is that you can do both. You can do both well and be successful in both if you really want to. It does take more effort to do both, and you'll have to work at it more than if you did one exclusively. It really depends on what you want to do, how much you love doing it and the amount of time and effort you want to put into it.

Pretty much like anything in life.

KG

 

[roja]

The question to ask yourself (and then the fellowships you are applying to) is what do you want to accomplish?

To you want to be a well trained EM doc in the community, working and making money? then you probably don'tn want to do a fellowship.

Do you want to be in an academic environment? Depending on where you want to be, you may or may not need to be a fellowship, depending on the institution and competitiveness.

Do you have a love of some area that you want to learn more about, have some dedicated time to explore and develop? Maybe a fellowship is a good idea, maybe not- depends on the area and what you want to learn.

Do you have a love of some area that you want to learn more about and build into your career (note: not necessarily your *practice* of EM: ie if you want to practice ultrasound, you don't need to do a fellowship, however, if you want to be an u/s director, teach ultrasound, do research in it, etc: you probably want to do a fellowship. Similar things can be said for almost all of the fellowships.)

Fellowships *should* have clear goals and objectives with clear plans on how those are met. Unfortunately, many are not regulated and there is wide wide variability in them.
So, once you decide to do a fellowship, you want to make sure that what you are wanting to accomplish can be done.

(ACGME is voting on making EMS an ACGME approved fellowship)

Fellowship is NOT necessary to be a qualified EM doctor. Its additional training for something more.