EM Needs More Emergency Department-Free Fellowships
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Hey arent you that [person] who thinks FPs should be managing ICUs?
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FPs should be eligible for ICU fellowships, just like IM, EM, Anesthesia, surgery are.
Not this again. Aren't you premed?
4th year med student
As much as I personally believe that residency, fellowship and the flexibility of them need to be desperately revised. I don't really think many FPs want to do inpatient medicine, nor are they trained well enough to think on their feet to deal with it.
Our education should not endanger patient lives. An ICU fellow from day one needs to be able to do a lot to get by without endangering lives.
There's a lot more than what is on paper that separates a standard FM residency from a standard IM residency. The most important being independence and familiarity/comfort with managing decompensating and critically ill patients.
Even good FM residents with large inpatient focus don't do enough rapids, critical care, procedure time. They also don't get an integrated perspective of acute illness physiology because they do significant less subspecialty time to do OB and Peds and MSK.
Might just be my school, but our FM residents are 50/50 inpatient and outpatient during their residency. I also am not saying this as someone going into FP. I am doing anesthesia. I just think if someone who trains in FP and has a lot of inpatient exposure during their residency wants to do a CCM fellowship, then that option should be there. If PAs/NPs are allowed to, why aren't FPs? The program at my school responds to all rapids, codes, and is trained in critical procedures. But again I understand this may be an anomaly as far as FP programs go.
This specifically has been debated multiple times on this forum. One meets the ACGME requirements to graduate an FM residency after seeing 15 ICU patients and 600 hours caring for adult inpatients. Most would agree these minimum requirements are not sufficient to produce comparable CCM fellows/specialists. There is variability in FM programs and do some programs provide more than others? Sure, but many don't and the minimum requirements are as I have stated.
As an MS4 you have limited critical care exposure to comment on this issue. Finish your anesthesia residency and we can see if you still feel the same way after you are done, but I doubt you will. Your opinion that EM, FM, anesthesia should be able to pursue IM subspecialties like cardiology, GI etc. also lacks insight.
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Never said I was an expert on the subject, just rather I don't understand why in the ICU I've rotated in the ICU PAs/NPs run wild without any supervision but a FP with more training should be excluded from completing an ICU fellowship. Either get the PAs/Nps out of the ICU or allow FPs in. Maybe you can help explain to me why a PA is allowed to cover an ICU at night but a FP with a fellowship in ICU shouldn't be allowed.
Either a NP/PA is safe for the ICU and so should a FP trained intensivist, or they aren't and the argument can be made only a IM/Anesthesia trained intensivist is safe for the ICU. I don't know which one is right.
I don't agree with midlevels running wild in the ICU, ED, anesthesia, consult services, or wherever. This primarily is the product of corporate medicine - administrators trying to reduce costs. The solution to this problem isn't to reduce the standards and requirements needed to be considered a specialist physician who is an expert in a specific area of medicine.
The longer that medicine is like this, the more normal reduced standards will become. I'd still rather have a FP-trained intensivist than a NP/PA if I were to end up in the ICU, but agree that IM/Anesthesia/EM are probably the most capable intensivists as critical care is more embedded into the residency before doing a CCM fellowship.
You're missing the point. Explain to me how the existence of an FP pathway prevents a hospital administrator from staffing a unit with a large number of midlevels? Do you really think the existence of this pathway is going to suddenly make a hospital administrator want to pay 4-5x more to have a physician instead of a midlevel?
that's a good point. I guess the FP would maybe accept a lower salary, but I can see how that is not a good thing for the field.
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Why would they? You're either a critical care specialist or you're not. Are you advocating for two different tiers? Perhaps you think the creation of an FP pathway would suddenly result in more CCM fellowship positions? Because it wouldn't, that is a totally separate issue. You haven't thought your opinions through very well.
Is there a big shortage of CC trained doctors and empty CC fellowship spots that FPs could fill? Unless the answer to both of those is yes, I don't see the point.
There is a shortage of PCPs. Do we want to make that worse as well?
Nevermind
Guys honestly this whole job market thing is making me burnout and depressed. ITs making me think why EM is even a speciality, it should have been a 1year fellowship or something.
ill graduate at 29 yo, Im strongly considering applying to a second residency, which ones would you do?
ill graduate at 29 yo, Im strongly considering applying to a second residency, which ones would you do?
Apply to DR this upcoming year. Your PGY1 will count as a prelim.
So, you've posted something like this, actually, many times, so, if possible, can you explain it to me like I'm 5 years old? What's the difference between hospice and palliative care?
When you look at the definitions, side by side, they're nearly identical. However, I think I asked this, several years ago, in the HPM subforum, and got the "they are very different", like a toad and a frog are very different, or a brown squirrel and a black squirrel are, or a crocodile and an alligator. (In other words, they're not).
So, as a friend, can you break it up for me?
Palliative is for people with serious illnesses at ANY point in their disease trajectory.
Hospice is for people with serious illnesses at the END of their disease trajectory, ie, 6 months or less. (Usually a LOT less. One of my biggest Ivory Tower cancer center typically sends me patients who have exactly 4 days. Seriously.)
That's why palliative needs to get involved in severe burn patients from the beginning. Those folks have heavy disease burden that palliative can help with. They also tend to have bad PTSD and post-ICU syndrome and lots of long-term issues. There is also a more delicate dance with the other specialties as palliative often tends to be treating both the patient and the moral distress of the consulting team, especially in the hospital. There is a definite consulation etiquitte which is very instutution dependent. With hospice, it's usually just me. Occasionally there's a community attending who wants to stay involved, or a specialist who just happens to be really entwined and can't let go. (I have one local onc like that.)
My patients, or at least the vast majority, have a distinct end point. They are gonna die, and most of them sooner than later. That gives me a huge amount of leeway that pretty much no other specialty has. There is no drug ceiling. There is no max. I also prefer the incredibly complicated ones. Give me someone with a crazy psychiatric history AND a tumor eroding their sacral plexus or maybe a full blown cord compression. Throw in a malignant bowel obstruction or maybe a carotid blowout. You know, make it spicy. Neuropathic pain. Maybe intractable tenesumus. Tumor encroaching on the tracheal lumen, the cord, the brain, the vena cava... Or maybe it's not cancer at all, but a guy whose alternating between pulmonary edema and orthostatic hypotension who is either too dry or too wet and can't stay balanced? Or someone who is so agitated that it takes a phenobarb infusion to take just the edge off. That's my style. An ICU without the vents.
I also don't really have to worry that my end stage cancer patient might actually go into remission and now is completely dependent on a crazy high opiate/benzo/ridiculousness dose. I do occasionally have people "graduate" so I am wary when I have someone that isn't definitely dying. I don't want to have someone end up having to go back to a community pain doc. (They are few and far between in these parts and these days, finding a local doc who will prescribe more than hydrocodone is hard.)
Clear as Mud?
Hospice is for people with serious illnesses at the END of their disease trajectory, ie, 6 months or less. (Usually a LOT less. One of my biggest Ivory Tower cancer center typically sends me patients who have exactly 4 days. Seriously.)
That's why palliative needs to get involved in severe burn patients from the beginning. Those folks have heavy disease burden that palliative can help with. They also tend to have bad PTSD and post-ICU syndrome and lots of long-term issues. There is also a more delicate dance with the other specialties as palliative often tends to be treating both the patient and the moral distress of the consulting team, especially in the hospital. There is a definite consulation etiquitte which is very instutution dependent. With hospice, it's usually just me. Occasionally there's a community attending who wants to stay involved, or a specialist who just happens to be really entwined and can't let go. (I have one local onc like that.)
My patients, or at least the vast majority, have a distinct end point. They are gonna die, and most of them sooner than later. That gives me a huge amount of leeway that pretty much no other specialty has. There is no drug ceiling. There is no max. I also prefer the incredibly complicated ones. Give me someone with a crazy psychiatric history AND a tumor eroding their sacral plexus or maybe a full blown cord compression. Throw in a malignant bowel obstruction or maybe a carotid blowout. You know, make it spicy. Neuropathic pain. Maybe intractable tenesumus. Tumor encroaching on the tracheal lumen, the cord, the brain, the vena cava... Or maybe it's not cancer at all, but a guy whose alternating between pulmonary edema and orthostatic hypotension who is either too dry or too wet and can't stay balanced? Or someone who is so agitated that it takes a phenobarb infusion to take just the edge off. That's my style. An ICU without the vents.
I also don't really have to worry that my end stage cancer patient might actually go into remission and now is completely dependent on a crazy high opiate/benzo/ridiculousness dose. I do occasionally have people "graduate" so I am wary when I have someone that isn't definitely dying. I don't want to have someone end up having to go back to a community pain doc. (They are few and far between in these parts and these days, finding a local doc who will prescribe more than hydrocodone is hard.)
Clear as Mud?
So, would I be safe to say that hospice is a subset of palliative? Or, that is the biggest overlap?
I will remember that situation and drug for a long time.
It's a real pain in the ass.
Spending your whole life in the bathroom straining is an awful way to die.
Just saying.
Just saying.
Just ask Elvis.
dchristismi explained it well in her examples.
Another visual takes us to the old venn diagram:
Make a big circle and label it palliative care.
Make a smaller circle within the palliative care circle and label it hospice.
=
Not all palliative care services are hospice, but all hospice services fall within the realm of palliative care.
What dchristismi mentions in her posts by the words "do palliative" is often a reference to palliative medicine, which if we are being purists, is the medical subspecialty of providing palliative care to patients through that clinical framework.
They are all great parts of the forest to practice in.
I am sad that my palliative job doesn't have any home hospice coverage such as it did in fellowship. That said, we do take care of GIP hospice patients in our palliative unit, which is satisfying and meaningful in all the ways she noted earlier.
So, I think that's what I concluded above. Thanks.
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This sounds cool as heck. It’s too bad my palliative rotation in medical school was basically just managing fentanyl patches on chronic pain patients at the VA. Maybe I should check it out again.
Believe it or not, there was a time in history when emergency rooms were a new concept and board certified EM docs didn't exist. The resultant cluster f*** that was emergency care at the time made us quite necessary. We have been instrumental over the past 50 years in providing appropriate assessment and treatment of emergent conditions and coordinating hospital care. Our training has saved countless lives. Have some pride and know your history.
I will also freely admit that I have a unicorn gig. Like RAINBOW UNICORN.
Like the equivalent of an SDG where you make full partner after 6 months. A really rare setup. A purely GIP practice. (General InPatient).
I started dipping my toes in very slowly, basically covering weekends and holidays, coverage that was normal to me, but that other docs didn't want to do. I sloooowly increased that, got noticed by upper management (in a good way) and when it became apparent that they needed to have me sign on "full time," they really made me an offer I couldn't refuse. They needed me more than I needed them, but I realized how sweet a setup this could be if I played my cards right. I negotiated for less than 100% FTE anyway. Because I'm retired and I'm past the point of taking what I'm offered.
Now to be perfectly honest, I still do some admin stuff. Much of hospice is sitting around talking. I have manged thusfar to avoid taking on a "big home team" which for my hospice is around 50-80 home patients. Interdisciplinary Team Group meetings, where the whole team meets and talks about the home patients, are not really my thing, but it's a big part of hospice. Most hospice docs really love the home visits. I don't and I avoid them like the plague. You pick your poison. But I cover for my colleagues when they're on vacation. I also take admission call for certifications and help out the NPs with clinical stuff when things push their limits which is usually pain management.
So my inpatient practice is a teeny tiny circle in the Venn diagram of Frazier's bigger Venn diagram.
I'm not saying these jobs aren't out there, but you have to have a hand in making them happen. But they're possible.
But also, continuity of care (in normal patients! Not typical ED patients!) is shockingly lovely.
Like the equivalent of an SDG where you make full partner after 6 months. A really rare setup. A purely GIP practice. (General InPatient).
I started dipping my toes in very slowly, basically covering weekends and holidays, coverage that was normal to me, but that other docs didn't want to do. I sloooowly increased that, got noticed by upper management (in a good way) and when it became apparent that they needed to have me sign on "full time," they really made me an offer I couldn't refuse. They needed me more than I needed them, but I realized how sweet a setup this could be if I played my cards right. I negotiated for less than 100% FTE anyway. Because I'm retired and I'm past the point of taking what I'm offered.
Now to be perfectly honest, I still do some admin stuff. Much of hospice is sitting around talking. I have manged thusfar to avoid taking on a "big home team" which for my hospice is around 50-80 home patients. Interdisciplinary Team Group meetings, where the whole team meets and talks about the home patients, are not really my thing, but it's a big part of hospice. Most hospice docs really love the home visits. I don't and I avoid them like the plague. You pick your poison. But I cover for my colleagues when they're on vacation. I also take admission call for certifications and help out the NPs with clinical stuff when things push their limits which is usually pain management.
So my inpatient practice is a teeny tiny circle in the Venn diagram of Frazier's bigger Venn diagram.
I'm not saying these jobs aren't out there, but you have to have a hand in making them happen. But they're possible.
But also, continuity of care (in normal patients! Not typical ED patients!) is shockingly lovely.
Fellowship just for hospice? Probably not.
Partly because there is a solid backdoor board certification pathway for hospice, but it covers everything (the vast majority of hospice is outpatient) which is a LOT of medicare regulatory guidelines.
Plenty of docs learn it on the fly, although I don't know how well they do it. I took it upon myself to learn because I don't do things half@ssed- but it was exciting and new and I was ready for a change. The texts are not massive - it builds on the knowledge you already have. I picked up on a lot as I went... like that you have to have a certain about of subcutaneous fat for a fentanyl patch to work. You can't slap one on a cachectic cancer patient and expect it to reliably work. Stuff like that.
The Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care is a tiny book (with tiny print) but it's fantastic.
The Primer of Palliative Care is another excellent one but less crammed full of pearls. For comparison to Tintinalli, they would both fit in a scrub coat pocket. Probably together.
The hospice I liked most and referred most to had nurses based at my hospital and it felt like I was calling them all the time. We just started talking and one thing led to another. Well actually, she commented to a family that "(her hospice) had been trying to recruit (me) for years." After the fact I pulled her over and just asked. And less than 48 hours later I was meeting with the medical director and went from there.
So you don't have to cold-call... just send out feelers to your admitting teams and see who they like, who they would recommend to take care of their grandma. You know, the question that's on every EM reference (but I've never seen on any other specialty, so I assume it's an EM thing.)
This was something I ended up finding out and liking unexpectedly, also. Just in the past month I've had the following "thank-yous." One lady, who I give periodic intercostal nerve blocks on, gave me and my nurse some homemade jam. Another patient, and "old guy" who had a lot of relief after a couple of epidural steroid injections, gave me a "Old Guys Rule" t-shirt. I had another tell their friends, who told my wife, that I "saved his life repeatedly the past 5 years." I didn't, but apparently doing q 3 months lumbar injections made him feel that way.
I got that in the ED some, but it's a lot easier for patients to do, when they know they're going to see you again.
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It does feel good to get follow up.
I've had some patients bring me some rather strange gifts.
A bottle of moonshine.
A Bible.
A set of Replica Pittsburgh Pirates World Series rings.
One little old lady wrote to the local paper and mentioned me by name back when @dchristismi and I worked at the same shop. Still have the clipping somewhere.
Wow. That’s awesome. I have yet to get any of those things. One lady did give me a little handmade knitted cross with a little prayer in it. I actually keep it in the pocket of my white coat either for good luck, to ward off evil spirits or maybe because I didn’t know what else to do with it.
1. I didn't drink the moonshine. No... no way. The sentiment was nice, though.
2. The Bible is pretty cool. Has my name on a small plate on the bottom corner on the cover.
3. The World Series Replica Rings were from a fellow Pittsburgher. Apparently, he worked with a company that did these things. I used to wear a Pittsburgh Pirates pin on my ID badge, and he recognized it. Those... those are pretty damn cool. I wore them on the day that I retired my student loan debt, just to play "gangster". I did see this patient like 4 or 5 times for various (legit) complaints. We got to know each other.
Okay, so here's the really weird thing; but it deserves to be said.
I saw a guy for kidney stone a few years back. Young guy, early or mid 30s. It was his 2nd or 3rd kidney stone. The guy looked terrified. Too terrified for a simple kidney stone. So, I tactfully pressed the item a bit, and learned that he had been declared "cancer free" from colon carcinoma not long ago and was terrified that this indicated a recurrence. I gave him the news that nothing looked sinister on the CT and gave him a hug. I'm a hugger. The people on here who know me IRL will tell you that I really wear my heart on my sleeve. As it turns out, the fella is quite the accomplished nature artist; has had his work featured in a significant number of exhibitions. I dig nature, too. Guy gives me his card; tells me to check out his website. I do. Send him an e-mail thru the website to tell him that I enjoyed his work. Didn't expect a reply; thought it would just go to [email protected] - but no, it got to him. Homey e-mails me back to say thanks, and that he's doing very well. Casual friendship is struck; a few e-mails before tapering off in the typical and expected fashion.
A few years later, I got another email from him with his phone number. Asked me to call him. Fella is in hospice, Stage-IV colon cancer. Asked me to stop by if it wasn't too out of the way. Of course I did. Guy is wasted away to nothing, but is still in good spirits. Says that he's got something for me, and gestures over to a cloth cover over a big rectangle; says its mine.
I was stunned. One of his works from the website, entitled "A little Something to Ease the Pain". Oil on original colored book page ephemera. Original book page was printed in.... 1857.
I got word that he passed shortly thereafter.
Lol.....
Hey, I can type "no obvious radiographically evident acute process" faster than nighthawk...
🙂
this past week I took care of a woman in her 40s for syncope. She was well put together, in workout-clothes, just overall looked like a healthy woman.
One of the first things I asked her was "you look great, you look totally healthy! You have any medical problems?"
She smiled at me through her mask, chuckled a little bit, and then picked up the portable oxygen tank next to her and said "yea see this?"
Turned out she had pulmonary fibrosis, scleroderma, and about 10 other diseases most of which I learned about in med school and then forgot.
Her workup was fine, I discharged her, and after she left the nurse came running to me and said "Dr. TheGenius (LOL, obviously not), the patient in 12 told me to tell you to give her a call. Oh doctor...you made a good impression! la la la"
Tape it to your forehead while you work
