EM to FP

[Atlas]

Do EM Physicians frequently enter family practice after many years in the ER? I'm curious because I'd imagine that after 25-30 years in the ER, a doctor may want to "slow things down". Can anyone provide some insight into this matter? Thanks.

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[edinOH]

I've known of a few EM docs who decided in their latter years of practice that they preferred the slower more predictable pace of a clinic type of environment. I don't know if you could say that they truely entered FP but some have chosen to work in a more primary care type setting after leaving the ED. Many choose to go to work for or open their own urgent care clinics. Others find happiness in a semi-retired setting working in fast-tracks in an ED.

I for one hope to bank away enough money to have the luxury of just walking away after 20 years or so of practice. Or maybe I will join the professional poker tour...

 

[Pegasus]

This is a good question..I have wondered the same thing. I am sure that after 20 years you will have more say on your hours. And dont forget, where you practice in EM makes a HUGE difference..rural vs urban. I am hoping that maybe an Urgent Care setting may be an option.



Pegasus

 

[DrQuinn]

When I was a young lass in college, I asked some of the EM attendings at the local hospital (all who were EM trained), and they said "Hell no I would never go into FP, I'm EM trained and will stay in EM until I die." This was the consensus amongst about 4-5 of them (they were in their 40s and 50s).

Q, DO

 

[Atlas]

It seems to me that life as an ER doc at 60 or 65 years of age may be a little hazardous to one's health. That's why I asked. I figured that ER docs at that age would prefer a "slower pace" so they aren't literally killing themselves. I don't know...I guess if the ER doctor can have more control over his/her hours so that (s)he maybe works 2 days a week to stay engaged, but not work so much that it becomes unhealthy, I don't see a problem with that. I also would assume that with everything a physician sees in the ER (all the variety), (s)he would be more than qualified to handle patients in a FP setting. The acute care setting is interesting. How does a doc go about getting into something like that? Can a FP boarded physician opt to work in an acute care clinic or must it be an EM trained doc? That option is definately something to consider when choosing between EM and FP...looking down the road (I mean) at where you see yourself in X amount of years. Thanks for your replies.

 

[DrQuinn]

From all the EM docs I've talked to about their future plans (probably around 20 or so)... most say they are just going to retire. I know a handful that are taking about 40-50k a year out of their salary and are going to retire after they have about 1.5 million saved up... so they won't need to work...

EM physicians are different from other specialties. We tend not to be lazy, we tend to LOVE what we do... so I think the idea of burnout and "wanting it slower" doesn't apply as well as you'd think.

Q, DO

 

[Atlas]

I apologize for the misunderstanding. I didn't mean to say EM docs were lazy or didn't love what they do. I mean...I wouldn't go into a field that I didn't love or feel passionate about and I'm sure most doctors feel that way. I guess because I have no idea what it's really like in an ER (only been in a few slow community hospitals a couple of times) it's hard for me to relate. I start at OU in the fall and have no "clinical" experience in the ER and have only TV shows like Trauma-Life in the ER to go by. From what I've seen and heard thusfar, on TV and in person, I think it would be a good field to go into. I'm glad you cleared that up for me because I've been thinking this whole time that ER's are much busier than I've seen in person...like on TV. Also, I can understand how a person would want to stay in a field that they love so much until they die. Thanks.

 

[meanderson]

An EM physician isn't qualified to open up a FP/IM practice. They aren't trained in long term maintenance care. I don't know if HMO's and insurance in the area would reimburse an EM physician to open a FP clinic and bill under his/her liscence for regular office visits.

EM physicians can go to work at quick-stop clinics, med-stop's, urgent care clinics, fast-track clinics, whatever you want to call these places.......This would be a viable option for an older EM physician who wants a slower pace and more reasonable hours.

 

[DrQuinn]

Originally posted by Atlas
I apologize for the misunderstanding. I didn't mean to say EM docs were lazy or didn't love what they do. I mean...I wouldn't go into a field that I didn't love or feel passionate about and I'm sure most doctors feel that way. I guess because I have no idea what it's really like in an ER (only been in a few slow community hospitals a couple of times) it's hard for me to relate. I start at OU in the fall and have no "clinical" experience in the ER and have only TV shows like Trauma-Life in the ER to go by. From what I've seen and heard thusfar, on TV and in person, I think it would be a good field to go into. I'm glad you cleared that up for me because I've been thinking this whole time that ER's are much busier than I've seen in person...like on TV. Also, I can understand how a person would want to stay in a field that they love so much until they die. Thanks.

When I was a pre-med, I felt how you did about ED's... all I had was my experience in rural EDs and what i saw on TV... I believed that EM was very fast paced and EXTREMELY quick-thinking. BUT! The real ED is very very very very very much unlike what you see on NBC's ER (we do NOT do heart transplants in the ED! And perimortum c-sections are exceedingly rare, although I think i've seen two on ER)... and Trauma: LIfe int he ER is edited... trauma codes don't end in 2 minutes like they do on the show, they last 15-30 minutes.

So do not fear the ED... and if you do love EM (like I do), you know what you are getting into, and won't get "burned out."

The statistic of the "average life of an EM attending is 10 years" is archaic. It comes from the 60's and 70's when there were NO EM residencies, and it was OB/GYNs, ENTs, Anesthesia, FP, IM, Surgeons who ran the ED... they were not residency trained, and did not necessarily PICK the specialty of EM. Now that EM residencies numer over 100, and the majority of urban and suburban EDs are filled with ABEM or ABOEM certified members, those burnout rates are muhc much muhc lower, as you are getting people (like me) who know what they are getting into and are trained FOR EM.

Q, DO

 

[maxheadroom]

Another important point that hasn't been made (in this particular thread) is that the age of FP/IM/Peds docs working in EM is ending. As the numbers of EM-trained docs grows quite rapidly, the jobs in EM for non-EM trained physicians will quickly disappear. Therefore, if you want to be an ER doc, you should do EM. If you want to do FP, do FP. Don't do one thinking that you can do the other. It's a disservice to both yourself and your patients.

 

[DuneHog]

Originally posted by QuinnNSU
The statistic of the "average life of an EM attending is 10 years" is archaic. It comes from the 60's and 70's when there were NO EM residencies, and it was OB/GYNs, ENTs, Anesthesia, FP, IM, Surgeons who ran the ED... they were not residency trained, and did not necessarily PICK the specialty of EM. Now that EM residencies numer over 100, and the majority of urban and suburban EDs are filled with ABEM or ABOEM certified members, those burnout rates are muhc much muhc lower, as you are getting people (like me) who know what they are getting into and are trained FOR EM.

It's probably too early to tell if the EM residency trained folks will burn out, although I'll admit that the "statistic" of 10 years sounds a little short to me. EM is a relatively young specialty and most EM trained people haven't been doing it long enough to get burned out. Personally, I don't think that ER docs of the past got burned out because they didn't choose to do EM. EM has always been (and continues to be) a high-stress specialty because, as one would expect in the "emergency" room, all fo the patients you see are there with emergencies (at least as defined by the patient). It doesn't help matters that a significant number of the patients are drug seekers and the dregs of society that are often difficult to deal with. Also, ER docs are constantly criticized and second guessed by the doctors from services they consult and admit to. However, the main reason I think ER docs burnout is because EM lacks the continuity and long-term relationships with patients that keep a lot of older docs going.

That said, EM is a specialty enjoyed by a lot physicians, particularly younger, high-energy types. However, the people in my medical school class who chose EM almost universally picked the specialty because they liked the idea of shiftwork and they didn't want to put in the number of hours required for internal medicine or surgery.

 

[BellKicker]

Originally posted by maxheadroom
Another important point that hasn't been made (in this particular thread) is that the age of FP/IM/Peds docs working in EM is ending. As the numbers of EM-trained docs grows quite rapidly, the jobs in EM for non-EM trained physicians will quickly disappear. Therefore, if you want to be an ER doc, you should do EM. If you want to do FP, do FP. Don't do one thinking that you can do the other. It's a disservice to both yourself and your patients.

Can someone tell me if this is true? I brought up the subject in the FP forum and the overwhelming response was that especially rural ERs are and will be staffed mostly by FPs. I suppose the posters in the FP forum could be biased but it seemed like they knew what they were talking about.

 

[Apollyon]

Originally posted by BellKicker
Can someone tell me if this is true? I brought up the subject in the FP forum and the overwhelming response was that especially rural ERs are and will be staffed mostly by FPs. I suppose the posters in the FP forum could be biased but it seemed like they knew what they were talking about.

I thought the projection was in 2015 or 2020, so the interpretation of "quickly" is open.

However, it may become difficult in rural, low-volume ED's to secure EM-trained and boarded practitioners without expenditures of an exorbitant amount of money.

One estimate from a little over a year ago is that 25% of all FP graduates go to work in ED's. My own, individual, personal belief is that the FP is truly the 'next best thing' to an EM-trained doc to work in the ED. I don't know if it is legion, but, at our institution, the FP residents do ATLS with EM and surgery.

 

[NuMD97]

Another important point that hasn't been made (in this particular thread) is that the age of FP/IM/Peds docs working in EM is ending. As the numbers of EM-trained docs grows quite rapidly, the jobs in EM for non-EM trained physicians will quickly disappear. Therefore, if you want to be an ER doc, you should do EM. If you want to do FP, do FP. Don't do one thinking that you can do the other. It's a disservice to both yourself and your patients.

I don't know how true this is actually. A friend of mine working at a university hospital in the southwest, under the FP umbrella, was just made director of one of the ED clinics. So at least for the immediate present, I would have to say that this is not true.

 

[maxheadroom]

Allow me to clarify:

If you want to be an ER doctor, you should do an ER residency. The exception being that if you want to be a rural FP or Med/Peds person, you will probably always find work in the rural ERs. Sure, there are people who were medicine and FP who were grandfathered in by ACEP, but that route is no longer open.

 

[hndrx1a]

ISN'T THERE ALSO A COMBINED ER-INT.MED PROGRAM? THAT WOULD GIVE MORE OPTIONS AFTER TENURE IN ER ...

 

[Airborne]

Th combined ED/IM programs I am aware of are 5 years in length. While this may be advantageous to some, I would think that for the many, one is best to choose either EM or IM - The extra 2 years in IM could be spent in a fellowship that can provide a very nice specialized practice and double the income.

 

[dr. strangelove]

the idea that emergency rooms should/will be head by emergency medicine docs only is not an overwhelming opinion nor majority. i'm not stating my own bias, but rather the current census. emergency medicine trained physicians are still relatively new, and there are a VAST number of physicians and directors who believe the emergency room should be head by internal medicine physicians and surgeons, with patient's being triaged into a 'medicine' problem or a 'surgical' problem.

the way the er is run, is quite different from hospital to hospital. ironically, the thinking is by providing this separation you are thereby not providing a disservice to the patient, in essence, allowing him/her to be seen by a specialist in that particular area for why they are in the er for in the first place. not the other way around as earlier stated by someone.

again, not my own opinions, but current thinking (which again varies from hospital to hospital and region to region).

 

[edinOH]

Dr. Strangelove,

Your "current thinking" is stuck somewhere in 1975. I don't mean to be rude but you obviously don't have a clue of what you are writing about.

 

[DuneHog]

I think most ER people would be surprised to learn that the sentinment that Dr. Strangelove expressed is shared by most non-ER people throughout the hospital. The reality though is that surgery and medicine do not want to run the ER. However, if they did I don't think they would have much trouble doing so, because the ER docs would have trouble finding support throughout the rest of the hospital.

 

[edinOH]

I don't disagree that many services within the hospital often don't appreciate the type and style of pt care that they perceive being provided in the ED. It is not uncommon for medicine and surgery et al to question our initial management or disposition of patients that they are later consulted on or have admitted to their service. This is usually explained by the fact that many unknown factors in the pts presentation are now better understood through completion of the initial work up, while others don't necessarily wish to look at the patient's case through the eyes of the ED physician. I think this leads to the sentiment by some that they could do a better job of managing pts in the ED than the ED physician.

I don't think that ED docs are better trained to manage medical or surgical complaints through resolution and definitive diagnosis than their medical and surgical counterparts. After all, ED physicians aren't internists, sugeons, pediatricians, or obgyns. They are however very good at the initial triage and management of most all of the things that the above specialists would typically see in their practice. That is where the value of EM residency training is found. ED physicians are experts at determining which complaints are most likely going to kill a pt. within the next minute, hour, or day and know how to appropriately manage such until definitive specialty care can be obtained. They are also adept at initiating definitive treatment for the conditions that aren't life threatening until a pt can be seen by their family doc or internist etc. They are experts at resuscitation because that is one of the hallmarks of EM training. Proficiency at these tasks is learned through the thorough and systematic mastery of what are considered the "Core Competencies" of EM through residency training.

The modern EM physician is a result of the identified need of a physician that is competent in the above mentioned areas. The irony is that the sickest pateints used to be seen many times by the least experienced or least skilled physician the hospital could find to staff the ED. This was due to what has been alluded to in the previous posts. Everybody thought they could do better, but nobody wanted to try! The internists and surgeons wanted better care for their pts in the ED but they were too busy with their own practices to do much about it. In the late 1970's some physicians began to identify themselves as "emergency physicians" primarily through work experience and their preceived need for quality consistent medical care. Around that time the first true EM residency was formed in Cincinatti. The rest is history.

The standard of care in most parts of the country in now residency training in EM if you wish to work in an ED. In most places it is an institutional policy to only hire EM-trained ED docs. This isn't the case everywhere, primarily in rural areas because the need currently is greater than the supply. This is rapidly changing though.

I have found that many of the younger attendings appreciate what an EM trained physician provides their pts when they present to the ED. I think some of the older ones still see the ED as the place that the weaker or more inexperienced docs go. As you work with more EM trained docs I hope you will appreciate the value they (in three years, we) bring to the patients.

Sorry this was so damned long. I thought some of you who don't fully understand EM might appreciate this. And sorry to hijack the thread.

 

[NuMD97]

ISN'T THERE ALSO A COMBINED ER-INT.MED PROGRAM?

Yes, as someone earlier answered. I just wanted to add that one of the fellows in the ICU had just completed a combined EM/IM program (five years) and now was embarking on a fellowship in Critical Care (another three years). How this all fits together pragmatically, frankly, I'm uncertain. Eight years is a very long time to dedicate to residency-fellowship training in the way that this fellow is doing it. Unless he's planning on moonlighting a lot in the ED during his training period and wants the ED expertise. Otherwise, I think he could have cut out the ED altogether and just gone the IM/Critical Care route. Or am I missing something?

 

[Apollyon]

Originally posted by NuMD97
Yes, as someone earlier answered. I just wanted to add that one of the fellows in the ICU had just completed a combined EM/IM program (five years) and now was embarking on a fellowship in Critical Care (another three years). How this all fits together pragmatically, frankly, I'm uncertain. Eight years is a very long time to dedicate to residency-fellowship training in the way that this fellow is doing it. Unless he's planning on moonlighting a lot in the ED during his training period and wants the ED expertise. Otherwise, I think he could have cut out the ED altogether and just gone the IM/Critical Care route. Or am I missing something?

Check out this thread, or this one.

 

[DigableCat]

A friend of mine's husband is a FP. He works in a "doc in a box" low level triage environment in an urban city. And it doesn't look like he's losing his job anytime soon. After working in the ER both at my medical school, and then as an intern, there are many things(but not all) that could easily be handled by an FP or IM with a consult to Gen Surg if needed. In the end, it all comes down to money I suppose though. EM docs salaries are alot more then the IM/FP counterparts. And if the community can't afford an EM, they'll find that FPs or IMs doing a little "ER" work will do just fine.

 

[deleted6669]

if you go the d.o. route there are also em/fp residencies(5 years) leading to dual board certification.

 

[DrQuinn]

Originally posted by DigableCat
A friend of mine's husband is a FP. He works in a "doc in a box" low level triage environment in an urban city. And it doesn't look like he's losing his job anytime soon. After working in the ER both at my medical school, and then as an intern, there are many things(but not all) that could easily be handled by an FP or IM with a consult to Gen Surg if needed. In the end, it all comes down to money I suppose though. EM docs salaries are alot more then the IM/FP counterparts. And if the community can't afford an EM, they'll find that FPs or IMs doing a little "ER" work will do just fine.

You're right... most FP/IM/GS could work in a "doc in the box" environment. The vast majority of those patients are "fast-track-able"... such as lacerations, sprains, strains, fractures, URIs, headaches, *drug-seekers*, etc. Most anyone who graduates with some level of competency from any Primary Care Residency would be able to handle the "urgent care centers." However, if one compares the ED patients with urgent care centers, you are missing a lot of the critical-care patients, and those that need immediate resuscitation. How many FP's would be able to do a thoractomy? Or be cool doing two codes at a time? I know the FP residents where I did my core rotaitons at would NOT be able to handle that (in fact, most paid IM residents to do their ICU rotations...).

Like edinOH said, many hospitals now are requiring ABEM certified or eligible physicians. It just makes good patient-care sense.

Q, DO