EM Needs More Emergency Department-Free Fellowships

Started by Birdstrike
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Birdstrike

Birdstrike

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15+ Year Member
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Being employable only within the walls of an emergency department, gives hospital administrators tremendous power over your quality of work life, which affects your entire life and happiness.

Fellowships that allow you to be employable outside of an ED, like Pain, Hospice and Palliative and Sports free the death-grip administrators have over your career and life. They also inoculate you against the cancer that is Chronic EM Circadian Rhythm Depression, which you've been told is imaginary.

Keep in mind that unless there is a big push from EPs to make more ED-free pathways happen, there is a tremendous financial incentive to keep it from happening. The powers that be want EPs stuck in the ED, under their control. They don't want you free to walk out and find employment elsewhere, entirely outside of the system of EDs. They know that if you have the choice, eventually you'll get tired of the conditions they've created, and leave. If this is going to happen, a grassroots effort by EPs and EPs-in-training, needs to happen.

EM needs more Emergency Department-Free fellowships. Make it happen.
 
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@Birdstrike is indeed wise. I've worked in two outpatient fields accessible from EM. Since I started doing that, the ED admins have treated me waaay better than when I was a full-time pit doc.

The more fellowship options the better.

EM should also have post-residency training options set up to do primary care and psychiatry. I'm talking about legit paths that will lead to board certification. This will defend those fields from incursions by random docs who take CME/weekend courses to "do them," help defend those fields from midlevel mayhem, be better for patients, and overall lead to better career options and longevity for EM docs.
 
namethatsmell said:
@Birdstrike is indeed wise. I've worked in two outpatient fields accessible from EM. Since I started doing that, the ED admins have treated me waaay better than when I was a full-time pit doc.

The more fellowship options the better.

EM should also have post-residency training options set up to do primary care and psychiatry. I'm talking about legit paths that will lead to board certification. This will defend those fields from incursions by random docs who take CME/weekend courses to "do them," help defend those fields from midlevel mayhem, be better for patients, and overall lead to better career options and longevity for EM docs.
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Which two outpatient fields?
 
Dakota said:
I agree there should be more opportunities for fellowships that allow for work outside the ED

This would help with the projected workforce over supply as well as helping facilitate mid career transitions. To echo birdstrikes point it would help improve ED conditions as it would allow physicians to walk (or at least threaten to do so).

To be fair - you would then need to allow other specialties to do legit Emergency Medicine fellowships that lead to board certification - which has traditionally been anathema to those in EM.

What would this look like? I think it would be fair to consider a two year fellowship pathway for those in FM, IM, and anesthesia (maybe peds, and psych?). In exchange EM could do a two year fellowship in any of those fields as well as apply to any of the IM fellowships. All of these pathways would then confer full board eligible status. Thoughts? I suspect IM wouldn’t bite on this but perhaps you could get the other specialties on board.

Medicine needs to allow more opportunities for lateral moves.
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It's time for physicians to be collaborative instead of exclusive. Physicians shouldn't exist in all these siloes and barriers that are put up to divide the profession, and if someone wants to become double boarded but not do an entire new residency and fellowship they should not have to do so. It makes no sense why certain fellowships can't be done by various specialties. I understand super-specialized ones that require the previous residency experience to do them, but a large portion of IM fellowships do not necessarily require IM residency only.
 
Rekt said:
I would do a FM fellowship to leave EM.
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RustedFox said:
- and you just graduated from residency.

... oh, and me too. I would do FM.
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FAU has a Geriatric Medicine fellowship which was accepting EM refugees this year. Interesting concept, it was unclear last I checked if you’d actually be board certified in geriatric medicine and how the specifics would work.

I imagine that could end up being a viable lateral for EPs that want to work outpatient down the line if it ends up working out for them.
 
I didn't do a fellowship. I would like to say it was more of an apprenticeship, but it was really more of a "you can probably figure this out on the job" situation and eased into it. If I was doing hospital-based palliative, I probable would have wanted a fellowship, but doing only hospice, and focusing on just inpatient hospice at that, (my specific choice) let me be very narrow and do it the way I did. With experience I *could* do the outpatient stuff now (and I do occasionally cover a team and sometimes serve as director) but deliberately don't.

And YES, my previous ED director did come crawling back asking if I'd "come out of retirement" one he'd boxed himself into a corner by saying that they didn't want any part-timers. Their loss. I said that nope, I was very happy following my true calling, and that I "was meant to do this." I didn't laugh in his face at least. But I wanted to.
 
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I totally support EM getting primary care/prev med, rural med, hospitalist, behavioral health/addiction, wound care fellowship.

Try applying and see how receptive the programs are.

Index -- AAFP

www.aafp.org www.aafp.org
 
CCM-MD said:
Hilarious. A lot of Dunning Kruger in this thread.
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It's simply a matter of survival. EM is not sustainable as a career for most people, even though they think it will be when they're 27. There need to be established pathways out (I've already found mine). But the rest need to make EM better by making themselves more employable outside of one room, in one building, controlled by people who don't care about their job satisfaction. Not only does that insure against burnout (which is a big problem in CCM, also, which I'm sure you know) but it gives them more leverage with those who control their work environment and see no problem with tightening the screws on their job market, work-life balance and mental state.

EM physicians aren't going to quit making our lives and careers better because @CCM-MD got a case of the Dunning-Kruger-internet-troll-lolz.
 
Birdstrike said:
It's simply a matter of survival. EM is not sustainable as a career for most people, even though they think it will be when they're 27. There need to be established pathways out (I've already found mine). But the rest need to make EM better by making themselves more employable outside of one room, in one building, controlled by people who don't care about their job satisfaction. Not only does that insure against burnout (which is a big problem in CCM, also, which I'm sure you know) but it gives them more leverage with those who control their work environment and see no problem with tightening the screws on their job market, work-life balance and mental state.

EM physicians aren't going to quit making our lives and careers better because @CCM-MD got a case of the Dunning-Kruger-internet-troll-lolz.
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I get where you are coming from. CCM has a lot of the same issues as EM.

As someone who did 3 years of IM, I am sure you can see why reading the following can be aggravating. "Is there any reason EM couldn't do cardiology, GI, Nephrology or any number of IM sub-specialties? We arguably already know more about GI and cardio than IM-trained physicians." Coming from an ER doc who has probably never stepped foot in any subspecialty clinic or consult service since medical school.

Birdstrike said:
I'm EM boarded. I do kyphoplasty's and spinal cord stimulators. Does that count?
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Yeah it counts! You're a neurosurgeon!
 
CCM-MD said:
reading the following can be aggravating...



Yeah it counts! You're a neurosurgeon!
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Let me know when you want to add something useful to the conversation. Sarcasm and venting aggravation don't count.
 
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Birdstrike said:
Let me know when you want to add something useful to the conversation. Sarcasm and venting aggravation don't count.
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I see you edited your post. Here is the useful point I am trying to make: stating EM physicians "already know more about GI and cardio than IM-trained physicians" is ridiculous. I am also very usefully pointing out out the hypocrisy of the situation. EM physicians trying to keep other specialties from practicing EM and vehemently opposing EM fellowships at one point citing the differences of an EM residency, are now wanting shortened training pathways to practice those exact fields they were so different from.
 
CCM-MD said:
Not liking what I have to say doesn't make it useless.
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The thread title is "EM Needs More Emergency Department-Free Fellowships." If you can type words that help us do that, it would be greatly appreciated. It's possible it might even apply to and help Critical Care Medicine.
 
Why more fellowship? We just love fellowships, don't we. If there was a "botox" fellowship, doctors would fill it up. Meanwhile, NPs would take a weekend course and get same outcome. Medicine is already now a house of cards and physicians are no longer captains of the ship. We are just well paid (for now) worker bees.

EM physicians are in a unique position because of our flexible work schedule to be entrepreneurs. We need more physician CEOs and business men/women that can run things and take back medicine. We should be training physician leaders in the medical school. 3yrs of clinical/basic science + 1 yr of MBA should become the new standard if we're to survive.
 
Seriously tho, if a NP can open a clinic and practice independently and have insurance cover their care,,, why the f can't we? this is BS.
 
Kryptocoin said:
Why more fellowship? We just love fellowships, don't we....3yrs of clinical/basic science + 1 yr of MBA should become the new standard if we're to survive.
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I've always liked the idea of more M.D.s doing MBA's as a way to increase their skill stack, and to help wrestle more control of our system back from non-medical trained MBAs and politicians (JDs). Good suggestion.
 
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Is a MBA useful though? Across the board, I've heard again and again that an MBA isn't worth the money, regardless of profession. Unless you get into some ivy league program where the connections formed are actually more valuable than the degree itself...
 
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hector10 said:
Seriously tho, if a NP can open a clinic and practice independently and have insurance cover their care,,, why the f can't we? this is BS.
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You make a good point. NPs think outside of the box and aggressively conquer more turf. Yet here we have docs choosing instead to troll and sit back and tell each other what they can't do. No wonder the underdog NPs are steadily gaining yardage on the team they weren't supposed to be able to beat.

Keep the positive ideas coming, people. Ignore the trolls.
 
bravotwozero said:
Is a MBA useful though? Across the board, I've heard again and again that an MBA isn't worth the money, regardless of profession. Unless you get into some ivy league program where the connections formed are actually more valuable than the degree itself...
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I think you're right in that the utility depends heavily on where you do it and what you do with it.
 
Birdstrike said:
You make a good point. NPs think outside of the box and aggressively conquer more turf. Yet here we have docs choosing instead to troll and sit back and tell each other what they can't do. No wonder the underdog NPs are steadily gaining yardage on the team they weren't supposed to be able to beat.

Keep the positive ideas coming, people. Ignore the trolls.
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Advocating to "conquer more turf" like NPs. Lets make patient care unsafe together, what a "positive idea". Bravo.
 
Docs have it all wrong with wanting to do other fellowships. Eventually most fields will be conquered by CMGS/Hospitals/VCs. Nothing is safe. HCA is opening up Derm residencies for goodness sake. Derm will be dead in a few decades and be in line with all office based practices.

Most docs are either risk tolerance or have poor business sense. Most EM docs make 300K. It is EASY to create something that has passive income.

Take 100K/yr and put it in to Stocks with high div returns or do property investing. Banks love docs and have good programs towards high income earners. In 10 yrs, you will cash flow 1-200K/yr then do what the heck you want at 40.
 
bravotwozero said:
Is a MBA useful though? Across the board, I've heard again and again that an MBA isn't worth the money, regardless of profession. Unless you get into some ivy league program where the connections formed are actually more valuable than the degree itself...
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Yes, the utility of an MBA is mainly in the networking. Right now, doctors don't have a seat at the table where the decisions are being made. Medical schools can design a program where students can be exposed to industry leaders. Hear and see how decisions that affect us are being made.

Another utility is learning the basics of a business. How many physicians can write a basic business plan enough for a bank to approve a loan?
 
Docs don't need a business plan to get FIRE in 10-20 yrs. If you want to take out a big loan to open up a business then may be good to get an MBA b/c docs are not fiscally restrained and need to think of a medical practice as a business first and not care first. If care comes with a successful practice then great but you can't provide good care if you are hemorrhaging money.

Save up 100K, put down on a rental property in year 1. Do this once a year for 5 years. Some will cash flow, some won't but most will have gone up in value. Refi vs sell and take the cash plus your 100K that year into more properties.

Most docs doing this should have 5-10 properties in 10 yrs with high equity unless you are living in NYC/SF or the like. After 10 years if you want to decrease risk, put 100K paying down debt. In 20 yrs you would have 10 properties with most cash flowing/high equity/paid off. You should cash flow 100K min with 2+M in equity. Now cut back on your work and enjoy living a reasonable FIRE life.
 
can I get opinions on HPM vs CC fellowship, CC is def more interesting but no flexibility , while HPM is overrun by not doctors and can practice independently after an orientation and here I am delaying completion of training.
 
hector10 said:
can I get opinions on HPM vs CC fellowship, CC is def more interesting but no flexibility , while HPM is overrun by not doctors and can practice independently after an orientation and here I am delaying completion of training.
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Like the 'not doctors', you don't need a HPM fellowship to do hospice either. But are you ok with foregoing taking care of critically ill patients? If not, then CC it is.
 
emergentmd said:
Docs have it all wrong with wanting to do other fellowships. Eventually most fields will be conquered by CMGS/Hospitals/VCs. Nothing is safe. HCA is opening up Derm residencies for goodness sake. Derm will be dead in a few decades and be in line with all office based practices.

Most docs are either risk tolerance or have poor business sense. Most EM docs make 300K. It is EASY to create something that has passive income.

Take 100K/yr and put it in to Stocks with high div returns or do property investing. Banks love docs and have good programs towards high income earners. In 10 yrs, you will cash flow 1-200K/yr then do what the heck you want at 40.
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These are great suggestions I think people should ponder. However, some people want to still be a doctor, yet don't want to have to do it at 3 am or on Christmas. Fellowships allow one to remain a doctor, yet not be tied to an ED, which is attractive to some. Not everyone wants to be a landlord, although I think it's an excellent suggestion for people who are interested, have the skill set, or the interest to learn it.

All ideas to allow EPs to earn a living outside of a hospital-based ED, are welcome.
 
Fellowship is great but most job will eventually be a beat down when you have to work. When you work on your terms or work when you want, then every job becomes much better.

Now that I am essentially FIRE, work is so much better as I have cut down on hours.

I agree that EM needs more fellowships to give docs option and unload on the supply.
 
emergentmd said:
Fellowship is great but most job will eventually be a beat down when you have to work. When you work on your terms or work when you want, then every job becomes much better.

Now that I am essentially FIRE, work is so much better as I have cut down on hours.

I agree that EM needs more fellowships to give docs option and unload on the supply.
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I agree we need more options, but what new fellowships or training tracks could be available, other than some kinda year primary care fellowship I really can't think of a new fellowship that would get us out of the ED.
 
bravotwozero said:
But are you ok with foregoing taking care of critically ill patients? If not, then CC it is.
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Hey now, I have plenty of critically ill patients. They just happen to have different goals of care and life limiting illnesses. To get to me, they also have to have symptoms that can't be managed at lower level of care. (ie, not by just an NP) I'm not good at easy boring stuff, so I don't do that part.

Try to manage acute cord compression without a neurosurgeon, a radiation oncologist, or a hospital. It's harder than you think. And maybe this patient wants to stay alert as long as possible because he might have to marry his high school sweetheart. Oh, and he's only 23 and dying.

Or a pain crisis in someone already on dilaudid at 40mg/hr + versed at 15 mg/hr + ketamine + lidocaine + phenobarbital who is still moaning and crying and has wasted away to 80 lbs. Who might also be suffering from some terminal restlessness which is brutal for families to watch.

Floridly psychotic? Yeah. Those too. I don't have the blowdart of Geodon 20 I had in the ED, but I have nurses who aren't afraid to go big with repeat doses of haldol.

You need to think outside the box young padawan.

I do have nurse practitioners. They handle the straightforward stuff. I get the challenges. I like it that way. But not too much. I am retired, after all.
(Full disclosure: I have a 0.8 FTE unicorn gig, full benefits, and they know I can handle anything they throw at me. I started part time 1099 IC and made myself so valuable to the company they made me an offer I couldn't refuse. Now, the NPs - and the other docs sometimes - call me for advice because I'm not afraid to throw a proverbial Hail Mary or think way outside the box.)

***Editing this post because Frazier in the post below makes an excellent point that I want to highlight - I ONLY do hospice. and I also pretty much ONLY do inpatient high-acuity hospice. If I was going to do palliative, or someone asked me about palliative, especially hospital based, yes, you should do the fellowship. It's only a year, and it's super high-yield. Being a hospice medical director is much more administrative - it by itself doesn't require a fellowship either, but there's definitely a learning curve. I've been doing this for 3 years and just recently sat for that board.
 
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Like the 'not doctors', you don't need a HPM fellowship to do hospice either. But are you ok with foregoing taking care of critically ill patients? If not, then CC it is.
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As alluded to by the doc above, HPM is a different type of acute care.

One of my GIP patients required a 24 hour utilization of 384mg IV hydromorphone via PCA (7,680 OME), 716mg ketamine PCA, 240mg midazolam, and 400mg thorazine. Still in pain. Still agitated. Still traumatic for family.

To frame that opioid utilization for you, remember that 4mg morphine you gave last shift in the ED? That is about 12 OME. Try 650x as much.

That's one patient. On a decent size census. All dying. All with symptoms. All with families. All with needs.

In today's day and age I always recommend fellowship. And not just waltzing into a position looking for a "quick out" from EM or a way to make some extra cash.

There is a learning curve. It is a subspecialty. You need to provide your patients with the best care possible -- especially these patients.

I'm aware dchristismi didn't do fellowship and she is great at what she does. But it the trend today is to be formally trained in the field as the old pathways are being phased out. Also she has a passion for her craft so she therefore practiced that craft and improved through her apprenticeship as she called it.

I dont get the same sense of dedication at all from ED docs that says "should I apply for this hospice medical director job? EM is burning me out. Can I do this without taking call? Can I open a cash based practice?"

Strolling into a hospice position, or god forbid a palliative position, when you dont even know the difference between those two terms is bad for you, bad for the field, and most importantly bad for patients.
 
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Agreed.

- What about Emergent Psych - with psych bed shortages everywhere, patients get held in EDs for days waiting for placement
- Observation medicine - if you obs a patient to a medicine service for something that should take less than a day (like cp rule out) they often stay quite a bit longer. We work 24/7, discharge people 24/7. No one would be better at turning around basic medical cases with quick 6-12 hour turnarounds than us.
- Telemedicine (for outpatient stuff)
- Telemed for interfacing with smaller hospitals/EDs as a consultant
- Hospital proceduralist
- Pain
- More of a foothold into critical care
- Admin - I'd argue no service line interfaces with the hospital more than the ED. We dip our toes into literally every other dept at least in some way. I'd argue that no group of docs is better at seeing the bigger picturer than us since we interface with so many other departments
- Addiction medicine

I'm sure there are plenty more.
 
Nice thread even if I'm not EM. So here's a question. Assuming money wasn't a big issue would it be totally crazy to get a masters in therapy and open a niche practice working with docs? It would probably be as long as a psych residency but way less grueling. And if you just want to do therapy and not full spectrum psych it might be an option?
 
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Crabbygas said:
Nice thread even if I'm not EM. So here's a question. Assuming money wasn't a big issue would it be totally crazy to get a masters in therapy and open a niche practice working with docs? It would probably be as long as a psych residency but way less grueling. And if you just want to do therapy and not full spectrum psych it might be an option?
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Interesting. You'd be a licensed therapists and qualified to do therapy as many non-psychiatrists do. But also as an MD, able to prescribe. Interesting.
 
If ER docs can work at micro hospitals or ED OBS units and MICUs, I don't see why hospital medicine can't be learned. It's really not that hard.
 
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