EM/IM combined program

DIVA01 · Aug 8, 2006

What is the advantage of these programs? Where are they offered, and what would you do once you were done?

Thanks!

drsutter · Aug 17, 2006

i graduated from one, it's a waste of time. Other than you've gained more knowledge in IM, it's kind of useless in your practice because your job is to quickly stabilize patient, not to sit and think for hours for the treatment and diagnosis.

drsutter · Aug 17, 2006

And may i add, because it's such a useless combination, that's why it's a dying residency.

MedWiz · Aug 17, 2006

DIVA01 said:
What is the advantage of these programs? [...] and what would you do once you were done?

DIVA01 said:
Where are they offered,

http://www.saem.org/rescat/imem.htm

HTH

deuist · Aug 18, 2006

Not the search feature! I'd rather people start new threads that force old topics to work their way back onto the main page. At the same time, we'll convince aging attendings to come out of SDN retirement and re-post the same answers that they've been using for the past two years.

GeneralVeers · Aug 18, 2006

Not much point in doing IM if you're doing EM and vice-versa.

They are such different ways of thinking, and practice in completely different environments with different goals that they don't combine well.

If you're interested in EM, then do an EM residency. If you want to do IM, then do that. Gotta choose. No fence-sitting radiologists around here.

drsutter · Aug 18, 2006

Hate to agree with the post above, but it's true based on my personal experience. I am grateful to my IM/EM training and i do feel that i know more IM than other EM doctors, but that doesn't translate much to ED work.

chocomorsel · Aug 19, 2006

drsutter said:
Hate to agree with the post above, but it's true based on my personal experience. I am grateful to my IM/EM training and i do feel that i know more IM than other EM doctors, but that doesn't translate much to ED work.

Thanks for the response. Coming from someone who's actually lived it. Now I know to just stick with ER.

iatrosB · Aug 19, 2006

Well, looks like everyone agrees that IM/EM is not a good combination. What do guys think about the new trend of EM/FM? Are they more similar than IM and EM are? They both have broad scopes of practice, but EM still has a much more acute mindset. Input?

zinjanthropus · Aug 19, 2006

iatrosB said:
Well, looks like everyone agrees that IM/EM is not a good combination. What do guys think about the new trend of EM/FM? Are they more similar than IM and EM are? They both have broad scopes of practice, but EM still has a much more acute mindset. Input?

Is there any additional usefulness of an EM/IM in the setting of a ED with an attached 24 hour observation area? Would an EM/IM trained individual be any more equipped to handle such a unit?

BMW19 · Aug 20, 2006

What about Urgent Care? It seems the two disciplines could be more closely aligned in this new emerging field. I have heard that there actually Urgent Care fellowships on the horizon I guess branches of IM/FM. It seems that there are many urgent care facilities popping up. Perhaps training in both of these fields could help you here...

BMW-

GeneralVeers said:
Not much point in doing IM if you're doing EM and vice-versa.

They are such different ways of thinking, and practice in completely different environments with different goals that they don't combine well.

If you're interested in EM, then do an EM residency. If you want to do IM, then do that. Gotta choose. No fence-sitting radiologists around here.

KGUNNER1 · Aug 21, 2006

iatrosB said:
Well, looks like everyone agrees that IM/EM is not a good combination. What do guys think about the new trend of EM/FM? Are they more similar than IM and EM are? They both have broad scopes of practice, but EM still has a much more acute mindset. Input?

I would disagree with this statement. There is nothing wrong with combined programs in general such as IM/Peds, Psych/Neuro. The candidates that go into these really need to know WHY they want additional training. For 99% of residents the traditional route is just fine. I'm sorry if some EM/IM grads now think they made the wrong decision and feel like they don't use their skills effectively to warrant the additional 2 years, but don't judge 100 of graduates just on the opinion of one or two on this forum. You'll find resident grads in all fields that are disgruntled for a number of reasons.

There are many EM/IM grads doing creative things that break up the "routine" of either specialty alone. Some are observation unit directors, others round on the floor and ED, still others go on to do fellowships like CCM or Cards then take those skills to improve the delivery of care to the ED they work in. We love what we do and would make the same decision over again. It works for us because we had an idea of how we wanted to apply the dual training. None that I know were undecided and did it just because it sounded interesting.

When the vast majority of patients in any ED (even level 1 trauma centers) are medicine patients, the extra knowledge and perspective of IM training will definitely refine your approach. You will understand the limitations of both services very well and the nuances about IM management problems that will start occurring in the ED as their lengths of stays approach 12-24 hours waiting for beds to open up.

Can you be a good EM doc with out it? Absolutely, but don't disregard the EM/IM route because it "wasn't for you". The reason many programs closed, was due to Medicare ruling back in the late 90's that limits the amount of training Medicare will pay for. Combined programs weren't included so these programs only got Medicare $ for 3 years rather than the 5. The hospitals that wanted to continue to support these programs did so out of their pockets.

Just keep in mind; you really need a good reason to do both. If you don't, then you shouldn't. If you see yourself just practicing either IM or EM exclusively 10 yrs. from now, in private practice, then it probably isn't for you.

kg

8744 · Aug 21, 2006

BMW19 said:
What about Urgent Care? It seems the two disciplines could be more closely aligned in this new emerging field. I have heard that there actually Urgent Care fellowships on the horizon I guess branches of IM/FM. It seems that there are many urgent care facilities popping up. Perhaps training in both of these fields could help you here...

BMW-

What on earth is the point of an urgent care fellowship? The point of urgent care is that while it may be urgent, it's not particularly serious.

You may not know it as it is not common knowledge but there is a specialty which deals with acute life-threatening medical problems and serious trauma and it is called..um...er...Emergency Medicine.

Maybe medicine is gettig to specialized. What's next, a "School Nurse" fellowship?

Miami_med · Aug 21, 2006

Panda Bear said:
What on earth is the point of an urgent care fellowship? The point of urgent care is that while it may be urgent, it's not particularly serious.

You may not know it as it is not common knowledge but there is a specialty which deals with acute life-threatening medical problems and serious trauma and it is called..um...er...Emergency Medicine.

Maybe medicine is gettig to specialized. What's next, a "School Nurse" fellowship?

There are a couple of posts about this in the General Residency Forum

Herpeto · Aug 30, 2006

I am considering an IM/EM combined program. My goal is to work in the ED three day a week and then follow up with IM Wards or personal IM practice the rest of the week. Am I being naive? Can this be done? The other option for me is an academic position.

deleted87716 · Aug 30, 2006

Panda Bear said:
What on earth is the point of an urgent care fellowship?

Urgent care is just primary care without an appointment.

waterski232002 · Aug 31, 2006

Herpeto said:
I am considering an IM/EM combined program. My goal is to work in the ED three day a week and then follow up with IM Wards or personal IM practice the rest of the week. Am I being naive? Can this be done? The other option for me is an academic position.

I suppose it is possible. I knew a Peds/Peds EM attending that did this. He worked mainly in the Peds ER and then had clinic once a week. I do not know of any adult EM attendings which do this. In reality, almost all EM/IM grads choose one specialty or the other (EM almost always wins).

KGUNNER1 · Aug 31, 2006

Herpeto said:
I am considering an IM/EM combined program. My goal is to work in the ED three day a week and then follow up with IM Wards or personal IM practice the rest of the week. Am I being naive? Can this be done? The other option for me is an academic position.

Typically the IM services will want you to rotate more than a couple of days/week. The fewest I've seen (aside from covering just the non-teaching hospitalist service) has been 1 week. Most are 2 week blocks, and some are even 4 week blocks.

If you do want to round on the floor on a teaching service, you'll probably round for 2 weeks a month, for maybe 4 to 6 months/yr. The rest of your time will be in the ED. You won't do both at the same time (round during the day and work an ED night shift).

kg

jashanley · Sep 10, 2006

I'm finishing EM/IM this year and I am doing a 3 yr fellowship in pulm/critical care. I absolutely would do my residency again. My plan is to do primarily critical care and some EM on the side. I have'nt decided what to do with the pulm aspect but the ability to bronch and bill is a bonus. If you want to do EM/IM, don't listen to the naysayers. YOu have to do what you want to do. Some people really enjoy doing the combined programs and other don't. It s the same in every specialty. some loved their residency and some don't. Figure out for yourself what you want to do.

GeneralVeers · Sep 10, 2006

jashanley said:
I'm finishing EM/IM this year and I am doing a 3 yr fellowship in pulm/critical care. I absolutely would do my residency again. My plan is to do primarily critical care and some EM on the side. I have'nt decided what to do with the pulm aspect but the ability to bronch and bill is a bonus. If you want to do EM/IM, don't listen to the naysayers. YOu have to do what you want to do. Some people really enjoy doing the combined programs and other don't. It s the same in every specialty. some loved their residency and some don't. Figure out for yourself what you want to do.

We're not saying that people won't enjoy their experience with the residency. The consensus is that it would be hard to practice EM and IM, as one would probably take over depending on one's interests.

WestcoastMedicine · Sep 12, 2006

I am just a second year student, but I have question for those of you in the field. I understand the benefit of having a stronger IM backround for treating EM patients. What are the benefits of EM/FP ? Is it more feasible to work 3 days EM, 1-2 FP or 1-2EM, 3FP Shifts per week? More so than working both EM/IM? I enjoy treating primary care patients and dealing with health maintenance, but also love treating acutely ill patients. Thanks for the input.

iatrosB · Sep 13, 2006

LHUEMT911 said:
I am just a second year student, but I have question for those of you in the field. I understand the benefit of having a stronger IM backround for treating EM patients. What are the benefits of EM/FP ? Is it more feasible to work 3 days EM, 1-2 FP or 1-2EM, 3FP Shifts per week? More so than working both EM/IM? I enjoy treating primary care patients and dealing with health maintenance, but also love treating acutely ill patients. Thanks for the input.

Have you considered urgent care? You can do that with either FP or EM training alone.

deleted77919 · Jul 11, 2007

Keep in mind at a lot of places 3 12 hour shifts per week is full time for EM. I have a lot of respect for the guy who does that and then turns around and spends a lot of time in clinic (as in, I don't think it's possible to keep up that sort of pace for any length of time).

deleted6669 · Jul 11, 2007

KentW said:
Urgent care is just primary care without an appointment.

or for folks not smart enough to go to the emergency dept with a life threatening illness.......

truckibear · Apr 19, 2009

What i want to know is, can you do critical care with EM/IM without any additional training?

SoCuteMD · Apr 19, 2009

truckibear said:
What i want to know is, can you do critical care with EM/IM without any additional training?

In other words, can you do critical care without the fellowship? I doubt it.

AmoryBlaine · Apr 19, 2009

I think there are a few people out there who are EM/IM who work as emergency docs and take stints as hospitalists although I don't personally know anyone who does this.

It's probably a feasible job in an academic setting. I have never even heard of someone who splits their time between clinic and the ED.

In terms of following up your own patients -- from a compensation standpoint you are not going to want to be filling an IM practice with ED follow ups who don't have a primary care doctor. Plus logistically if you see someone for HTN and start them on meds are you going to be their doc for the rest of their life or yours?

I'm a big believer in picking your career. If you like internal medicine just do it. If you go to a solid program with some decent critical care time you'll get plenty good at stabilizing medical patients/running codes etc. It's not like you have to be boarded in EM to know how to take care of sick people. Similarly if you're already going into EM thinking of a back-up plan or a side career I would sit down and think about the career decision.

deleted65604 · Apr 19, 2009

2 problems I see with wanting to practice IM AND EM.

1. We need good, solid PCPs, who are available to their patients. You are doing noone a favor by only having clinic for 1-2 days a week and then working random ER shifts, and recovering from night shifts the rest of the time. The only way that is useful to anyone is if they happen to get sick or have a question on that 1 or 2 days where you are available. Or are you going to be fielding out-patient calls all day while you work the ER, or recover from a night shift?

2. ER has such an incredibly broad base of knowledge, that every hour spent practicing IM, and studying IM is an hour away from peds, ophtho, trauma, surgery, Ob-gyn, etc. I believe that the best ER doctor is a person who spends the majority of their time training and practicing in the ER.

I have a co-worker who did IM/EM. He is undoubtedly a great doc. Hhe has more IM knowledge than I do. However, he doesn't practice out-patient or in-patient medicine, so what was the point of spending an extra 1-2 years on pure internal medicine rotations?

My bias is that he would have learned more had he got out of residency and practiced ER on his own for that period, making good money, rather than making crap pay in residency and still having his hand held by attendings.

KGUNNER1 · Apr 19, 2009

Jarabacoa said:
2 problems I see with wanting to practice IM AND EM.

1. We need good, solid PCPs, who are available to their patients. You are doing noone a favor by only having clinic for 1-2 days a week and then working random ER shifts, and recovering from night shifts the rest of the time. The only way that is useful to anyone is if they happen to get sick or have a question on that 1 or 2 days where you are available. Or are you going to be fielding out-patient calls all day while you work the ER, or recover from a night shift?

2. ER has such an incredibly broad base of knowledge, that every hour spent practicing IM, and studying IM is an hour away from peds, ophtho, trauma, surgery, Ob-gyn, etc. I believe that the best ER doctor is a person who spends the majority of their time training and practicing in the ER.

I have a co-worker who did IM/EM. He is undoubtedly a great doc. Hhe has more IM knowledge than I do. However, he doesn't practice out-patient or in-patient medicine, so what was the point of spending an extra 1-2 years on pure internal medicine rotations?

My bias is that he would have learned more had he got out of residency and practiced ER on his own for that period, making good money, rather than making crap pay in residency and still having his hand held by attendings.

Jarabacoa,
Your points are common arguments. However, from the view of someone practicing both inpatient (critical care) and Emergency Medicine, you're not exactly "point on". It is true that most EM/IM grads end up practicing one or the other (usually EM). This is mostly a product of such a wide difference between lifestyle and salary between both specialties. Also, if you're not in a system with a hospitalist program, it is next to impossible to practice both.

I know several of my former classmates that practice both EM and hospitalist medicine (mostly in teaching hospitals). They enjoy wearing both hats breaking up the fast pace of the ED with more detailed medicine workups on the floor. Their teaching skills are better in both environments for their added perspective resulting in less "bashing" of either specialty. It brings both programs together.

I enjoy the same rewards rounding on complicated critically ill patients, teaching surgeons, anesthesiologists, and a whole slew of internal medicine residents and fellows. The ED is a nice break and the pace is fun. The really sick patients in the ED end up as great teaching opportunities that our residents won't get from the other ED attendings (and I highly respect all of my ED partners).

The comment about the IM component contributing to making one a poorer (sic) EM physician is just false. The vast majority of patients coming in the doors of all ED's (unless it is the trauma side of Shock Trauma or a peds ED) are adult medicine patients. We don't have to keep reading up on IM more than the EM doc has to. We learned it the first time around, and continue to practice it every day. The same is true with critical care.

From my perspective, as one who has chosen this pathway rather than just comment on it, is that if you want to combine an IM practice with an EM practice, you can do it. However, it will be much easier in a "shift" type model like a hospital service.

My $0.02.

KG

rockingdoctor · Apr 19, 2009

There are plenty of residents pursuing this combined residency, including 2 every year in my institution. Most of the folks going in this field are those who like the fast action packed life in the ED, yet at the same time wanna spend time doing research as well. The length of the residency (5 yrs) provides them adequate time for this.

And when you graduate, and decide to work in a rural area where is there is shortage of docs, then you being double board certified will be of a great value.

Drawing Dead · Apr 19, 2009

LHUEMT911 said:
I am just a second year student, but I have question for those of you in the field. I understand the benefit of having a stronger IM backround for treating EM patients. What are the benefits of EM/FP ? Is it more feasible to work 3 days EM, 1-2 FP or 1-2EM, 3FP Shifts per week? More so than working both EM/IM? I enjoy treating primary care patients and dealing with health maintenance, but also love treating acutely ill patients. Thanks for the input.

I'm doing an EM/FM residency right now. The plan was to do a sports med fellowship afterwards, for a total of 6 years. Yeah, it sucks, but its what I want to do. I would like to work full time (3-12s) and do a day a week in an SM clinic. Then, once I'm done with nights and weekends and my loans are paid off, slowly transition to primary care. But who knows. EM is still my first love, and I may just do that and let my FM cert go to waste.

megawhizz · Apr 24, 2009

I love my EM/IM training, and split my time between an inpatient academic rounding service and the ED. I strongly advocate the training for people who are interested in leadership positions in EM - whether they are looking for administration, research or teaching. It does NOT make you a better EM doctor - if that is your goal stay with an EM residency.

Also certain EM/IM programs offer an additional year to make it an EM/IM/Critical Care fellowship leading to ABIM certification in critical care. An excellent choice for people interested in EM critical care which is a rapidly growing field thanks in part to the long wait times all of our patient suffer from.

megawhizz · Apr 24, 2009

SoCuteMD said:
In other words, can you do critical care without the fellowship? I doubt it.

Yes, you can

. However ABIM certification in critical care (which is a requirement to practice in most large ICUs) is currently open only to EM/IM graduates. You can do a surgical critical care fellowship and practice in certain surgical ICUs, and many ICUs will take IM-boarded (and not necessarily fellowship trained) people, depending on their staffing requirements and applicant pool.

STIDO · Jul 16, 2009

ER docs do not know a lot of critical care...do not intubate a 24 YO with ph of 6.9...they will die....straight ER docs will not know the reason why...EM/IM would know

BADMD · Jul 16, 2009

STIDO said:
ER docs do not know a lot of critical care...do not intubate a 24 YO with ph of 6.9...they will die....straight ER docs will not know the reason why...EM/IM would know

Riiiiiight....

I hope that isn't your blanket policy as you will kill someone.

And you'd be surprised how much critical care many ED folks know.

Signed --> Toxicologist who is paid to teach EM critical care, not Toxicology.

BOHICA-FIGMO · Jul 16, 2009

jashanley said:
I'm finishing EM/IM this year and I am doing a 3 yr fellowship in pulm/critical care. I absolutely would do my residency again. My plan is to do primarily critical care and some EM on the side. I have'nt decided what to do with the pulm aspect but the ability to bronch and bill is a bonus. If you want to do EM/IM, don't listen to the naysayers. YOu have to do what you want to do. Some people really enjoy doing the combined programs and other don't. It s the same in every specialty. some loved their residency and some don't. Figure out for yourself what you want to do.

Still, that's an awful lot of tests to take every 10 yrs for recert!

BOHICA-FIGMO · Jul 16, 2009

truckibear said:
What i want to know is, can you do critical care with EM/IM without any additional training?

I doubt it, but there are exactly 3 places (as of 2008) that offer an EM/IM/CC residency in 6yrs: LSU-Shreveport, Henry Ford, and NY Long Island Jewish Hospital.

pseudoknot · Jul 16, 2009

BOHICA-FIGMO said:
I doubt it, but there are exactly 3 places (as of 2008) that offer an EM/IM/CC residency in 6yrs: LSU-Shreveport, Henry Ford, and NY Long Island Jewish Hospital.

I thought Maryland also had the 6-year option. They claim to on their website:
http://umem.org/res_emim_cc.php

DOMb · Jul 17, 2009

what are the avg step 1 scores at these IM/EM programs, for example, the UCLA one?

sleepymed · Jul 17, 2009

STIDO said:
ER docs do not know a lot of critical care...do not intubate a 24 YO with ph of 6.9...they will die....straight ER docs will not know the reason why...EM/IM would know

the 24 yo is dependent on their own repsiratory drive to blow off the metabolic acidosis by compensating with a respiratory alkalosis; if you intubate someone you won't be able to breathe fast enough for them to do what their own bodies are doing; it's similar to the teaching that you don't want to intubate an ASA toxicity unless you absolutely have your fingers tied.

-- from a lowly *only* EM in training

But as an EM physician i consider that, but I also recognize that if that patient is not protecting their airway or are not able to oxygenate well enough; the airway is most important and I can try to change vent settings (because yes we get trained on vent settings as ER docs) based on their blood gases... I will protect airway first as opposed to waiting 30 minutes for the BMP to come back

oh and as EM doc, a 24 yo person with a ph of 6.9, i would do a VBG on and only do an ABG after i had intubated...

I hate when people throw out condesending comments like this; the average board scores going into EM is higher than IM and we have some incredibly smart people doing EM now, please don't insult our intellegence...

BADMD · Jul 17, 2009

sleepymed said:
the 24 yo is dependent on their own repsiratory drive to blow off the metabolic acidosis by compensating with a respiratory alkalosis;\

Unless the patient has obstructive lung disease and has a PCO2 of 80 and a lactate of 5. Then intubation will help fix the acidosis and will fix the lactate by reducing work of breathing. A lovely alternative scenario for our friend above.

BOHICA-FIGMO · Jul 20, 2009

pseudoknot said:
I thought Maryland also had the 6-year option. They claim to on their website:
http://umem.org/res_emim_cc.php

Whoops, you're exactly right, I forgot about the Maryland program.

LadyKae · Dec 21, 2009

wondering if anyone out there has any more to say about the EM/IM/CC combined programs...there are a limited number of programs out there...is there any reason to think that the training would be better if one were to do an EM/IM residency and THEN casting the net wider for critical care training? especially if one is ultimately interested in working in academics?

megawhizz · Dec 24, 2009

LadyKae said:
wondering if anyone out there has any more to say about the EM/IM/CC combined programs...there are a limited number of programs out there...is there any reason to think that the training would be better if one were to do an EM/IM residency and THEN casting the net wider for critical care training? especially if one is ultimately interested in working in academics?

I can't see any reason why the training would be better, the board certification would be identical. You may have more time for research (and a longer fellowship) if you do a separate fellowship and that may help you secure a better academic job.

I know of three EM/IM/CC graduates - one is an NIH funded researcher at a Harvard affiliate, one is working in a major university in Houston in EM and CC and another in EM, CC and hospital administration (quality/safety) at a very large healthcare system in Detroit.

DartosDO · Dec 24, 2009

How difficult is it to get into the EM/IM combined programs? Are they harder because you have the IM component, or are they less competitive because of the extra yrs? Could I use it as a back door in the event I didn't match straight EM? I would rather do EM/IM than another residency I don't enjoy.

daveyjwin · Dec 24, 2009

DartosDO said:
How difficult is it to get into the EM/IM combined programs? Are they harder because you have the IM component, or are they less competitive because of the extra yrs? Could I use it as a back door in the event I didn't match straight EM? I would rather do EM/IM than another residency I don't enjoy.

My personal experience thus far has been that most places that have combined programs also have just straight EM programs. All the places where I applied to both, I got an offer by the EM/IM program, and not one from the EM program. After changing my mind about EM/IM to just straight EM, and letting the programs know, all of them switched my interview to just EM. I suppose the moral to this story is, if you want to do EM, just apply to EM, not the combined programs. If you may want to do IM someday, then do the EM/IM.

megawhizz · Dec 25, 2009

daveyjwin said:
My personal experience thus far has been that most places that have combined programs also have just straight EM programs. All the places where I applied to both, I got an offer by the EM/IM program, and not one from the EM program. After changing my mind about EM/IM to just straight EM, and letting the programs know, all of them switched my interview to just EM. I suppose the moral to this story is, if you want to do EM, just apply to EM, not the combined programs. If you may want to do IM someday, then do the EM/IM.

IAWTP. Back door to EM is highly discouraged. If you are not competitive enough for EM, you are unlikely to get EM/IM.

DrVanNostran · Mar 23, 2011

Any more information on these programs? I was wondering how competitive is it to get in? It seems like an attractive option for some people.

I would not mind working as a hospitalist full time and moonlighting as an EM doc on the weeks off.

Charting the outcomes doesn't have any info on these programs...

Saladin MD · Mar 23, 2011

megawhizz said:
IAWTP. Back door to EM is highly discouraged. If you are not competitive enough for EM, you are unlikely to get EM/IM.

Why is backdoor "discouraged"?

megawhizz · Mar 27, 2011

DrVanNostran said:
...I was wondering how competitive is it to get in?...

In general they are as competitive as the EM programs in the same institution.

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