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Any thoughts? Is the FP w/ EM fellowship more desirable for rural settings? Is it just for those who want the option to do either? Thanks!
EM residency VS family med w/ EM fellowship
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http://forums.studentdoctor.net/showthread.php?t=717014
http://forums.studentdoctor.net/showthread.php?t=773598
http://forums.studentdoctor.net/showthread.php?t=668757
http://forums.studentdoctor.net/showthread.php?t=616161
These are just some of the many previous discussions about this in the Emergency Medicine forum.
I'll add that we had a resident at my program who had completed a FM residency and an EM fellowship (FM-administered). He recognized that he was not really well prepared by those 2 programs to deal with everything that can present to the ED so he then came to us and completed an EM residency. Anecdotal, yes, but it takes a lot for someone to voluntarily do 3 more years of residency training.
http://forums.studentdoctor.net/showthread.php?t=773598
http://forums.studentdoctor.net/showthread.php?t=668757
http://forums.studentdoctor.net/showthread.php?t=616161
These are just some of the many previous discussions about this in the Emergency Medicine forum.
I'll add that we had a resident at my program who had completed a FM residency and an EM fellowship (FM-administered). He recognized that he was not really well prepared by those 2 programs to deal with everything that can present to the ED so he then came to us and completed an EM residency. Anecdotal, yes, but it takes a lot for someone to voluntarily do 3 more years of residency training.
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Ahhh thank you so much. For some reason, I only found older posts and I wanted a more recent response. Thank you for taking the time to hold my hand, as apparently my searching ability is sub-par
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This seems to come up often enough that maybe it should be in the FAQ?
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Done and done.
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To my knowledge, I've not worked with anyone BUT FM trained docs in the ED...some of which had been fellowship trained but most not.
To be honest, they did fine. If there are true trauma's, they go to the trauma center for the trauma surgeons to deal with.
To be honest, they did fine. If there are true trauma's, they go to the trauma center for the trauma surgeons to deal with.
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Aside from the quality/completeness of EM education, keep in mind that non-boarded ED docs are only going to find jobs in a rather narrow type of hospital. If you or your spouse decide you don't want to live in a rural area down the road, you might find your options limited.
D
deleted109597
A monkey can do trauma. That isn't a true showing of the differences between the training.
FM teaches FM. They will always be better at managing chronic hypertension, diabetes, and everything that requires primary care.
However, even with the fellowship, they aren't equivalent to EM docs. What they do might work, but to argue that it's ideal is comical. This is similar to the NP thread. Sure, if you do a study that doesn't identify the differences, you can show that they are "non-inferior". And for the vast majority of things, they probably are.
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So you are saying that you basically have no idea, and have never seen, how a residency trained EM physician practices. You can hardly claim to be an expert that says the FM trained docs practice equally as well in an ed as EM trained docs. Uneducated responses do nothing to help the OP answer his/her question.
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1. Never claimed to be an expert, nor did I say anything about them practicing like a residency trained EM physician.
2. You're a testy bunch. Sorry if not everyone shares your love (or respect) for the ED, and all that it entails...(a bunch of non-emergencies that cost us all WAY TOO MUCH MONEY to rule out true emergencies).
Note the "to my knowledge" precursor in my post.
When I worked as a RN in the ED I worked along side both FM and EM trained docs. The FM docs were good and could handle tough situations, but would spend more time per patient and in general order more tests than their EM trained brethren. The patients typically loved the FM guys, but more times than not their more methodical style would inevitably begin to back things up while the EM docs were more comfortable with "treating and streeting" the low level stuff without a lot of "extras". Just my experience.
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I agree that you were greeted a bit harshly, but this issue has come up many times here and often with the connotation that "any doc can function as a high quality EP"...and this is notion is false. You might not have intended to deliver this message, but imagine the response you'd get if you told an OB doc that her extra year of training is worthless since an FM docs learn about OB stuff too. Same sort of thing applies here.
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We do get testy about this subject. Much the same as other specialties do when people assert that they are unnecessary, overpaid or that any number of others could do their jobs better. And after all this is the EM forum.
We're not in a war with our FM trained colleagues but we do maintain as a specialty that the best physician to staff an ER is an EM trained and boarded doc.
I think that all of us know FM trained docs who do fine work. But that doesn't change the goal.
And if anyone would like to talk about the high cost of ED services I'd be happy to join in. I agree that we are too expensive when it comes to colds and sprains. Just understand that to fix that you need to start by writing your Congressman. We didn't pass the laws that led us to where we are now.
We're not in a war with our FM trained colleagues but we do maintain as a specialty that the best physician to staff an ER is an EM trained and boarded doc.
I think that all of us know FM trained docs who do fine work. But that doesn't change the goal.
And if anyone would like to talk about the high cost of ED services I'd be happy to join in. I agree that we are too expensive when it comes to colds and sprains. Just understand that to fix that you need to start by writing your Congressman. We didn't pass the laws that led us to where we are now.
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Is the problem not a lack of BC/BE EM trained physicians that are willing to work in some of these areas? Or, just a lack of numbers overall?
I never said they were doing anything better, for the record.
It is my goal upon completion of residency and my MBA to work on the many things wrong with medicine. The fact that every yahoo that walks into an ED and says any number of magic words automatically gets a very expensive workup (often at no cost to them) is a big problem in my opinion.
I never said they were doing anything better, for the record.
It is my goal upon completion of residency and my MBA to work on the many things wrong with medicine. The fact that every yahoo that walks into an ED and says any number of magic words automatically gets a very expensive workup (often at no cost to them) is a big problem in my opinion.
You seem to be implying that emergency medicine in general practices medicine poorly and that you know how to do it better. I wonder if such a passive-aggressive approach is truly the best reaction after being unexpectedly burned for what you didn't realize was an inflammatory comment. Especially after being given a nice way out by someone explaining how your initial comments were perceived.
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No. What I'm saying is we need to reform laws so that ED physicians can use clinical judgement and common sense to rule things out rather than CT's and other expensive (and harmful) tests. I happen to believe that physicians can and should be more than technicians that follow algorithms.
And, I've stated nothing but my opinions based upon experiences.
As for how to practice medicine, I will view it as my job to not only keep people from having to utilize the ED, but also to educate them on what is and is not an appropriate reason to GO to the ED.
During my rotations, I was continually amazed at the number of people that wanted to waste their time by going to the ED for stuff that was most definitely NOT an emergency. I'll state once again that it takes a special person to actually enjoy working the ED in its current state. I'm glad those individuals exist. I wouldn't be interested until a clinician can look at a girl with N/V/Abd pain that "thinks she might be pregnant" but obviously shows no signs of severe disease and say "fine...go buy yourself a pregnancy test and here's a script for some Zofran...now go home and make an appt. with your OB".
I think my favorite "emergent patient" was the 24 year old that called 911 for Nausea...then sat on her bed and took photos with her cell phone all the while bitching about how she was entitled to be seen RIGHT AWAY because, after all, she'd come by ambulance. It was hard to tell what was causing her "10/10" pain and "intractable vomiting" what with her screaming, bitching, and distinctive lack of emesis.
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I don't know the definite answer to this question. But I have been doing some researching in my home-state (where I would really like to end up after residency) to find out which residency programs their EM physicians trained at, and I have found that MANY of them... at least 20 percent... are FM or IM residency trained. This surprised me, especially because it was in a pretty desireable place (Colorado), where I would think it would be fairly easy to recruit EM-residency trained employees.
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from an EM perspective: "fine...go buy your self a pregnancy test and here's a script for some Zofran...now go home with your ectopic"
There's a big difference between FM and EM, as you have just illustrated.
And the work-up would be different also. FM = well, I can't say with any certainty, as I am not FM-trained...but I have seen two techniques.
One you mentioned above - the take your preg/abd pain/possible ectopic home; which is cheap and fast, but too risky for my patients.
The other I have seen (again, not FM-trained, so I am not saying this is what FMer's do, but I have seen it plenty): order a truckload of labs inlcuding Hep panels, HIV...perform a PAP smear!...pelvic exam...then wait six hours for the on-call radiologist to perform the TV ultrasound...which is crazy expensive and damn slow, which I don't want for my patients either.
The EM way: hcg, pelvic with TA/TV U/S to ensure IUP (when not on fertility drugs) and OTD to OB.
HH
...and I think for MANY "basic" work-ups (not just critical med and trauma), you will find similar difference in thinking, safety, and efficiency.
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We aren't just "technicians who follow algorithims." There are far too many different types of patients and variations of those types for everything to be algorithmic. Instead we train physicians over three years to deal with these myriad presentations in an ED setting, i.e. residency. We no more follow a cook book for everything we do than any other specialty. We have guidelines based on best practices for many things just like everyone else. E.g. we have chest pain pathways, FM uses JNC 7 guidelines for treating HTN.
That's all well and good but you're talking about a much more complex problem than people choosing to go to the ED for things they know are non-emergent. The uninsured are told by many entities (receptionists at doctor's offices, social services, EMS, employers, etc.) that they are supposed to get their care in the EDs. Others are refered into the ED by their PMDs because of liability concerns, clinic overflow issues and the inconvenience of getting preapproval for testing.
The system is broken. The overuse of EDs is a symptom.
Gotta go code somebody. More later.
D
deleted109597
Unfortunately, research has shown that the health care worker (from CNA to MD) can perceive the pain that someone is actually in. If they're pregnant and say they have abdominal pain, unless they're overly gravid, you have to rule out ectopic. Even with malpractice reform, I wouldn't send someone with pain out onto the street to rupture/die.
Not saying that you shouldn't strive for this, but you, as a MS that is sometimes in the department, even if you've got EMS/nursing/volunteering background, don't have all the experience you need for answers to this problem.
Putting undertrained people in the ED certainly isn't the solution.
While some might argue it's a turf battle, I don't think it's the same. Most of the EPs I know aren't arguing that they should fire the FPs that work in the rurals without having EPs that can take their place. They're arguing that they shouldn't be able to be called EPs or get board certification in that. Just like an EP can't call himself a radiologist even after completing an ultrasound fellowship, FM/IM/whatever should never be allowed to be called an EP. Otherwise we don't have a specialty, just a job.
I applaud FM docs that want to do the fellowship because they lack the knowledge after their residency to work in the ED. Hell, there's an EM resident at UNC right now that did FM first, then worked in EDs for years, but went back to residency. Now, I'm not sure if this is because he saw the writing on the wall and wouldn't be able to continue where he was, or if he wanted to work in bigger EDs, or if he was just doing it "to be better".
In the end, I don't think we will ever be able to staff every ED with EM docs. They can't even staff every ED with physicians currently. While some might say we are biased against the rural places, I think it is more that we are biased against working with undertrained people. Many of us moonlight in the rurals during residency, and experience the terrible checkouts we get from people who aren't properly trained in EM. There's no way I would go to that every day.
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I stand corrected. I have, in fact, never seen an ectopic present with a CC of "I think I'm pregnant, I need a pregnancy test...and oh yeah, I have Nausea".
I jest, but that is the type of thing I'm talking about. Not "I may be pregnant, and I have a pain that is reproducible and am in distress".
I do appreciate the candid discussion. Again, I have a lot of respect for the folks that like practicing medicine as it has to be practiced in the ED.
I jest, but that is the type of thing I'm talking about. Not "I may be pregnant, and I have a pain that is reproducible and am in distress".
I do appreciate the candid discussion. Again, I have a lot of respect for the folks that like practicing medicine as it has to be practiced in the ED.
I'd still rather identify the ectopic when it's "i may be pregnant and not in significant distress, but something's not right" so that they can have a Beta-quant, an Ob f/u in 2 days with repeat bloodwork, and possibly an offer of methotrexate, than when it's the "i'm pregnant, i'm in distress, my BP's bottoming out please get me to surgery". Although I will admit that the latter is more exciting and a true emergency.
Come on now.... You moonlight during residency? That can't be... Only board certified EM physicians who have COMPLETED an EM residency are adequately trained to work in the ED.
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Having only BC EM physicians staffing EDs is the ideal. From a numbers standpoint alone, that is currently impossible. EM residents are often moonlighting in places that have difficulty recruiting BC EPs, and there is a reason (that is usually not cost) that hospitals like to have EM training moonlighters.
I agree that, in general, it's best to have EM boarded physicians in the ED. I also agree that the only path to EM board certification is EM residency.
Most jobs, especially in urban areas are basically limited to EM trained guys anyway.
But you can't have it both ways.
There was an editorial in one of the throw away EM journals basically saying that NP's in the ED are acceptable, but FM trained physicians have no place around the ED. You can't argue... well I guess you can, but you shouldn't.... that FM + EM fellowship trained physicians still don't have enough training to work in the ED, but a resident moonlighting with half the training is somehow OK.
Most jobs, especially in urban areas are basically limited to EM trained guys anyway.
But you can't have it both ways.
There was an editorial in one of the throw away EM journals basically saying that NP's in the ED are acceptable, but FM trained physicians have no place around the ED. You can't argue... well I guess you can, but you shouldn't.... that FM + EM fellowship trained physicians still don't have enough training to work in the ED, but a resident moonlighting with half the training is somehow OK.
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For moonlighting, the residency for EM is focused almost exclusively on acute care, and usually takes place in high volume centers with large numbers of acutely ill patients. I would argue with your assertion that a moonlighting resident has half the training of an FM+fellowship (which will have significant amounts of non-acute care time) in regards to the ED.
While I reject the notion that FM residency+fellowship = EM residency, I actually don't have a problem with fellowship trained FMs as a stop-gap measure. Working in a tertiary care ED in an area where the outlying hospitals are staff almost exclusively by internists or retiring FPs, I wish more of them had any idea about basic resuscitation. Stuff like ASA/heparin for transferring MIs that didn't get lytics, or giving fluids for patients in septic shock.
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...former president GW Bush...The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.
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I was talking about this the other day with a colleague of mine, FM trained, working in urgent care. She likes it but really wants to be in the ED. She wants to go back and do an EM residency but can't really swing it personally (3 kids, self-employed husband, mortgage, etc).
We both agreed that a 1y EM fellowship isn't sufficient for full EM training, but we both got hung up (in a good way) on the idea of a 2 year FM (or IM or Gen Surg for that matter) --> EM fellowship. Sort of like the Peds --> Peds EM fellowships that nobody really argues with.
2/3 of the intern year in EM is spent either off service or (as in every other specialty), trying to find your ass with both hands, so 2 years of focused EM training following completion of another (clinical generalist) residency seems (to me at any rate) a reasonable approach to this issue.
Thinking out loud here and curious to hear others thoughts on the matter.
We both agreed that a 1y EM fellowship isn't sufficient for full EM training, but we both got hung up (in a good way) on the idea of a 2 year FM (or IM or Gen Surg for that matter) --> EM fellowship. Sort of like the Peds --> Peds EM fellowships that nobody really argues with.
2/3 of the intern year in EM is spent either off service or (as in every other specialty), trying to find your ass with both hands, so 2 years of focused EM training following completion of another (clinical generalist) residency seems (to me at any rate) a reasonable approach to this issue.
Thinking out loud here and curious to hear others thoughts on the matter.
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Actually, this is one of the best posts of the year, so far, on SDN.
The Peds EM example falls a bit short on two fronts: first, half the fellowships are 3 years for EM and Peds, whereas the other half are 2 years for EM and 3 for peds grads. The other is that the EM RRC says that there has to be a minimum percentage of peds cases (I don't recall if it is 16% or 20%). As such, an EM grad in Peds EM fellowship for 2 years still has had quite an exposure to the Peds ED.
As for the 2 years for IM or GSx post-residency training, there are two things both IM and GSx severely lack in residency (thankfully): peds and Ob/Gyn. 2 years for FM is already accounted for, as the new EM/FM combined residencies are 5 years. Why med/peds is only 4 years, vs. 5 years (at least) for every other combined program, has always been a head-scratcher to me.
You do make a reasonable point, though: could FM do 2 years of fellowship? Actually, it should really be 2 years of residency (ie, not supervising residents) - grinding it out. FM grads get halfway there - they are as likely as anyone to get 6 months credit for rotations done anyhow (and the six months is the max credit allowed).
D
deleted109597
Anyone can set up any shop after an internship. However, no insurance company would credential you for something you can't do. If you have enough cash payers, you could do endoscopic derm path surgery. I wouldn't plan on it though.
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I'm sorry to throw a one-liner in here... but have you looked at dual-programs?
5 years for BOTH board-certifications.
Otherwise, FM is better suited for the "urgent care" scenario, vs. the "emergent care" scenario. You could certainly make plenty of money at these afterhours, fast-track kind of places.
5 years for BOTH board-certifications.
Otherwise, FM is better suited for the "urgent care" scenario, vs. the "emergent care" scenario. You could certainly make plenty of money at these afterhours, fast-track kind of places.
What is urgent care vs emergent care? I see these occasional freestanding urgent care centers (some attendings call them doc in the boxes). Are you telling me these are actually run by FMs?
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Yep. It's easy money as the walk-in clinics are private practice and will only take insured patients. If there's ever a real emergency, they send the patient to the ED.
D
deleted109597
Fixed it for you.
If family docs can own their own urgent clinics, I wonder why the supposed average income of family docs is so low. Do some of them make a LOT of money but just go under the radar?
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Because urgent care clinics are under the same financial pressures as every other clinical entity. They have to fight for market share, manage overhead, etc. Their billing is lower than ED billing because they have less ability to handle complex, high acuity patients. Urgent cares are not treasure chests. I know several docs (EM and other) who have failed running them.
