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Discussion in 'Emergency Medicine' started by monkeymedic, Mar 20, 2016.
Good luck, black dynamite.
And apologies if I said anything offensive.
Update Sept 2016:
Hi Everyone! I've read through each and every message here, even the mindless grumblings which I will ignore
A quick update to bring you up to speed:
- I started my FM residency and the people here are really good to me so I think it will definitely be bearable for 3 years if that's ultimately what I have to do before deciding on how I want to pursue EM in my life. I still find myself longing for the ED on an almost daily basis, but our hospital treats us well so I can put up with it if I have to. After all, I see myself in this position as a job and not as the beginning of a career.
- Being at an unopposed residency program is actually giving me a lot more experience than I realized it would and I hope having an extensive procedure log might help with my transition to another program. I've talked to our EM education faculty here (we are unopposed but there are EM rotators from our sister hospitals that come through our ED) who has told me to keep very good logs as it could potentially help me in applying to another residency program. Since the residents here are responsible for running the hospital, I've volunteered to pick up the code pager at every opportunity I get. Basically everything except traumas (covered by our trauma fellowship) comes over it so while some of my colleagues find it to be a burden, I gladly will trade some of my notes for these codes! (Though last week where I had 12 codes in one day was probably a bit excessive).
- Based on the advice of people here, I've decided against trying to re-match this year. The risk of not matching and my PD replacing me is just too high. There's no reason to believe that I would have a better chance at matching with 3 months under my belt than last year--especially the reason I didn't match was due to my Step 1 Failure and not lack of experience.
- I think my most likely chance at finding a spot would be to look for vacancies after the match this year, either with programs that didn't fill, or programs that are new. I know there were a few of those last year. This decreases the chance of me being left out in the cold, or so I think, as my PD wouldn't have 9 months to try and find a PGY-2 replacement for me
- The other possibility is just waiting out the 3 years, doing my FM residency so I have some sort of backup and then applying for an EM residency. I have all but ruled out doing an EM fellowship at this point unless somehow it becomes recognized by ABEM.
I start my first ED rotation in a week or so. We have 1 month as an intern (mixed with procedures days so really more like 1-2 weeks), 1 (full) month as a second year, and 1 (full) month of peds ED as a second year. We also have 4 elective months that can be spent in EM. The goal is obviously to get some letters for whenever I decide to transfer to EM (whether after PGY1, 2 or 3). It's also not ideal, but if I had to, I could probably manage working in a rural ED. I agree with everyone here that FM does not train someone to the same standard as EM, but I would much prefer working in EM and "learning on the job" so to speak, than spending a career in FM. I have already spoken to the education director, in brief, who suggested that I try to match again this year after doing his rotation with him, but we never got around to the specifics of how I failed Step 1 etc.
Current Questions that I hope someone can help answer:
1.) Other than monitoring SAEM vacancy service and waiting for May or June to come when some programs might be trying to get off the ground but have missed the match so to speak, what else should I be doing if I'm hoping to snag a spot post-match this year?
2.) Other than trying to do well in my rotations, what other things do I control at this point that could make me have more appeal to programs as someone who is switching? I've thought of taking my Step 3 as early as possible and getting a full license so I can start moonlighting in rural EDs and perhaps even picking up some jobs as am EMS medical director, but other than lining my pockets with a bit of extra cash, will that actually be looked upon favorably by EM PDs?
3.) If I wait until PGY-3 to re-match into EM, I will have used up all of my funding. Is there a good way to figure out which programs care less about this? For example, my med school was so hilariously overcapped that this wouldn't have been an issue for them, but they are a large institutions with more overcapped residents than many programs have spots! Are there programs that are more friendly to those trying for a second residency than others?
4.) I've also seen some postings on SAEM that will take someone who has finished PGY-2 (rising PGY-3) in another ACGME specilaty into a PGY-2 EM position. Realistically speaking, what are the chances of this happening? I take it most PDs will want a rising EM-2 into their EM-2 spot and not a rising FM-3, but if they get a rising EM-2, then that opens up another spot and the cascade just happens until some non-EM2 fills the spot right?
As promised, I read through every post and will try to respond to every one, but I got a little behind so here's my responses to the more interesting posts:
Thanks for this suggestion. I'm monitoring the website frequently. There are only 2 posts right now. One for PGY-1 and one for PGY-2. They both look outdated!
Not sure what the first line means. I should be happy that I matched at all? I agree with that sentiment. It would be a lot harder to match after a year of being out, and while I don't love my job, I like it and it pays and that's the important thing at this stage of my life. If you're insinuating that I should be happy with a career in FM though, I find it a bit of a bold statement that you are telling me I should be happy in a field I don't have any desire to be in...
As to the third line, why is that bad advice? Because of the risk it would entail? The no-risk route is to finish off my 3 years of FM and rematch into an EM-1 spot or try to find an open EM-2 spot that will accept someone who "has successfully completed two or more years in an ACGME-accredited program in another specialty" (a line I see frequently when I see advertised PGY-2 spots). I originally thought I would go this route as I don't really like taking risks with the stakes this high. But now after a few months in my program, I'm seeing that it would be better to jump ship earlier rather than later, as I don't really find my work fulfilling and know I would much rather be doing EM so I'm finding a low-risk way of leaving (such as looking for spots only after the match to minimize the amount of time my PD has to find a replacement for me). Of course, I've gotten some terrible advice over the past 16 months including (as mentioned before) my home institutions PD telling me that I didn't need to apply to a backup specialty because he was sure I'd match somewhere, and a faculty member telling me to break my match agreement to pick up one of the open spots after the match...
I agree, I CAN do EM somewhere being FM trained, but there area a few issues with this. Out of the gate, compared to EM trained folks, I would be nowhere as good. Could I eventually get good over a few years of experience. I'd like to think so. After all, there are many attendings with decades of experience in EM who did FM or IM residencies who I would choose any day of the week over a freshly minted EM grad, but it'll take me longer to get to that point.
I don't mind working rural. I would actually prefer it initially in my career I think (I worked rural EMS throughout med school). But eventually when I want to have a family and settle down, I know I won't want to spend an hour or two of my day driving to and from work. There is a gentleman who graduated from my program last year who just started working as an ER attending out in the middle of nowhere. He actually still lives near here but commutes 2 hours each way to work. He makes more than the EM attendings at the med school where I graduated from (about 100k/year more actually) and I know part of it is private sector vs public/academic sector, but it's still not something I would want long term even if there is better/same pay.
This is true. I would argue that everyone that rotates through our ED is off service, since we don't have an EM program, but I would bet the EM rotators from other programs who are trying to get time at a L1 Trauma Center are held to a higher standard than our home rotators in FM. Of course, most of my colleagues take vacation during their EM month so I'm sure that doesn't help with their EM experience. I think the saving grace is that we still get a lot of critical care experience. We have an Open ICU so every one of our inpatient months, we do some critical care time. We also have a month (actually 2 months, but each is split with procedural days so it works out to me more like 1 month total) of ICU time that we spend with the ICU service (even though we have an open ICU, most unassigned patients still go to the ICU service). And as I mentioned, we're the only house officers in-house so if the ED or anywhere else in the hospital has a septic shock or other critical patient on nights and weekends, I potentially cover it if I'm carrying a code pager. (During the day, an FM-3 covers procedures). Still not ideal, but hopefully it'll set me up to be in a better position when I apply to an EM residency.
I saw that. But I was matched already at that point. One EM faculty member gave me advice to break my match agreement, but I think that would have been really bad advice. Really bad. Hopefully something like that happens again next year when I'm not bound by the match! Also, any idea what happened to them trying to get PGY-2s? I looked at their website and they only seem to have PGY-1's.
Thanks for the words of support. It's pretty stressful being in a program in a specialty I'm not too fond of but that treats me well and that I like, but I can only imagine what it's like for people who are in a program that they are miserable at or even worse, those that didn't match at all. Really puts things into perspective of how I should be grateful for what I do have.
EM at Rush - new program, taking applications (not in ERAS)
I knew a resident, Caribbean grad, who wanted to do EM/IM. Didn't match into it or into EM.
DID match into IM. Was very clear about end goal of being trained in both EM and IM. Did all of their elective time in the ER at my training program. Reapplied for EM at the end of IM residency and matched at 3 year program.
Now, I don't know if they ever had any intention of doing IM truly. But boy did they sell it.
The point that applies to you , is that they made no problem about being in IM and so it seemed very reasonable to just do another residency in EM.
I also think the reason this work is that they had one very simple clear reason: first they would work in an ED, and later in career do IM.
Now, I thought that was kind of a silly reason for me, but for them it made sense. No apologies, no wavering.
Don't screw over your FP residency. Even try to enjoy it. There are FP/EM combined residencies. So, one other way to approach this is...
Hey, this isn't what I anticipated, but I'm learning good stuff. Then apply to EM again. Everywhere. Your FP residency didn't want to be viewed as a subpar experience for someone who never expected to be there. Keep kicking ass, keep doing extra work, and if you're a top resident, they may even help you out to get an EM residency.
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I know plenty of FP and IM residents that graduated then started EM residency or worked a little then started. also plenty more that didn't but work in rural EDs or at the VA or military EDs. finish your FP program, learn a ton, then decide what you want to do.
I know this is a slight deviation from the topic, but has there been any more talk about fellowship programs in EM for those with FP or IM background? I know this has been a hot button topic in recent years with the ABEM being strongly opposed to such things. My understanding is that the ABPS does recognize these fellowships and considers them "board certified" via their own board certification process. Apparently some states recognizes this board certification and some states don't and there have been several legal battles to decide this. I understand that the ABEM is trying to protect the integrity of their specialty and feel that the only way someone should be able to work in the emergency department is after completing an official emergency medicine residency. However, there is obviously a fairly decent sized population of FP and IM graduates out there who would be interested in being able to get board certified in emergency medicine. Instead of having these board certified and licensed physicians drop back down into the match and compete with applicants who still have a full residency's worth of federal funding going for them, why not offer an alternate route to allow for previously trained physicians to work in the ED as board certified emergency medicine doctors. Obviously there is a significant amount of overlap between the two specialties as they are already willing to knock off 6 months worth of residency training for EM residencies for those are also getting IM training. If my memory serves me correctly, I've read that the projected shortage of EM doctors is so significant that the U.S. is not expected to have enough EM docs until around the year 2050. IM and FP are obviously more than qualified to handle anything on the medicine side of things that rolls through the ED (i.e. your COPD and heart failure exacerbations, PNA, AMS, pancreatitis, diabetic ketoacidosis, CP, etc...). I feel that instead of making them go back and complete a whole second residency why not offer a way for them to get the trauma training and surgical/ emergency issue management skills needed in order to be able to sit for the boards?? Make it a 2 year program... most medicine fellowships are 2- 3 years anyway. There are already programs out there like this, but they are just being shunned by the ABEM. I don't get it, are they just trying to protect their turf or something?? Any thoughts or information about this would be greatly appreciated.
You answered your own questions, twice - ABEM is attempting to protect our interests. By allowing other groups to claim that they also offer board certification, they weaken the integrity of our specialty as a whole. How is this not obvious to everyone?
One of the early obstacles at the beginning of our specialty was convincing the House of Medicine that EM is not something that "anyone could do." This brings me to another point you brought up about IM or FM trained physicians managing certain conditions in the ED - it is not that they lack the knowledge (that absolutely has not been my experience); rather, it is the mindset of working up these chronic diseases in an acute setting with an eye towards what will either harm the pt immediately vs what is most likely going on, while simultaneously managing a dozen other pts. Despite requiring essentially the same knowledge base, it needs to be applied differently and I think that the folks that like one versus another self select into EM vs IM/FM. Again, this isn't to say that an FP can't think like an EP; it's just that in order for an FP to practice EM, they need to do an EM residency. This is no different than if an FP wanted to do general surgery; they can have the knowledge, the stamina, the "surgical mindset," but until they have completed a GS residency, they are still just someone who thinks they could do surgery, rather than someone who is a surgeon.
If you want to practice type-X specialty, you need to do that specialty's training program. Giving any credibility to alternate pathways undermines both the specialty and those of us who choose to practice it.
Yes there's overlap, but there's overlap in every field. I would argue that EM docs are way more qualified than IM docs to become cariologists, would become great interventional radiologists, see a ton of psych and could probably learn to be a psychiatrist in a year or two, etc.
The fact of the matter is, each field protects itself and its board so the individual feel doesn't get over saturated. There are fellowships out there for FP. They're just not ABEM boarded. And hopefully they never will be IMO. I have a skill set for EM that is greater than an FP doc with a 1 year fellowship, and I deserve to be paid more than them. I dont want the market watered down and the boards considered equal. All specialties do this in terms of protecting their boards.
As for the statement that IM an FP doctors could walk into an ER and take care of any of the medical problems, I'm still laughing at that statement. An IM or FP senior resident rotating in the ED handles a patient load less than an ED intern. Procedurally, these residencies do not train residents to do the number of critical care procedures to be anywhere close to competent. And IM never sees a child. And how many have taken a foreign body out of an eye, reduced a fracture or dislocation, are credentialed in procedural sedation, do bedside US, etc. and its not just exposure to all this different stuff, but learning to manage the chaos in a productive manner. That takes years to do.
EM isnt medicine and trauma. It's medicine, surgery, trauma, ophthalmology, OB/GYN, Pediatrics, psychiatry, radiology (US and read your own films at night), cardiology, orthopedics, etc. The list goes on. Its the acute stuff of every field, and the only field that you experience stuff and have to know how to put out fires for every field of medicine.
In the end you can work in EM without a fellowship after an FP residency. Or you could do a fellowship. You can still work in EM. You just cant call yourself ABEM certified. If that is important to you, you'll have to do an EM residency. This is no different than an FP doc who does a dermatology fellowship or an OB fellowship. It's extra training for the FP doc, but they cant start saying they are boarded OB/GYNs either.
To play devil's advocate... up here in Canada we have 5 year EM trained folks like myself working alongside FP + 1 year fellowship docs in major metro centres and level 1 trauma centres. For the most part, we are indistinguishable. Maybe academically the 5 year guys are more productive, but clinically it's hard to tell us apart. I've worked with many FP + 1 docs that are better than their 5 year counterparts. I will say however that the EM residency puts out a more consistent product... but the well motivated family doc with extra training can certainly do our job and do it well.
Let me clarify... I am not suggesting that IM/FP should be eligible to sit for emergency medicine boards with their current training, but obviously there are barriers to going back and doing a second residency. One commonly brought up issue is funding... Uncle Sam does not want to foot the full bill for doctors to do a second residency. This makes many residency programs hesitant to accept those with previous training. All I am suggesting is that there be an alternate route for those physicians who decide later in life that they would like the additional certification (which would include being trained in emergency management in all the areas that you stated above). Instead, I see people suggesting that FP or IM docs go find a rural ED somewhere where they are more likely to be hired... Sounds like a great alternative. Most Emergency medicine residencies are 3 year programs...Why not offer a 2-3 year fellowship program from those with previous training so that they can acquire the right mindset for an emergency setting and become qualified to remove foreign bodies, work with peds, deal with chaos, handle surgical issues etc....One that makes them Board eligible. That way you don't have less than qualified people running amok in the rural EDs of America. I would argue that this would be in the best interest of the patients in these rural areas, wouldn't you? Previously trained IM physicians who successfully go back and do EM are often only required to complete 2.5 years of residency... Why not offer a fellowship program of equal length for those who decided later in life that they are better suited for the ED but are unable to get a residency due to GME funding issues and red tape.
I get your point, I do, but every field does this. You can't backdoor your way into being an Anesthesiologist as an ED doc later in your career despite having intubated and sedated countless patients. We structure GME training in a way that is controlled by the specialty to ensure that you are putting out a consistent product, and also to control for not oversaturating the market. The fellowships you ask for exist, they just aren't ABEM certification. You can work in any state in the union in any ED and the fellowship will certainly make you more prepared to do so. You just can't call yourself an ABEM certified ED doc and you can't teach EM residents. If you want one of those things, if those are important to you, then you should just do a second residency.
Believe me, I understand the frustration. I know there are people who desperately want to do EM only to have their spot taken by someone who might not actually be suited for the field but that just tests well. Thats unbelievably frustrating, and I recognize that. But you can't expect a medical board to give up all its power and control and just accept another boards training as equivalent. That's not going to happen, nor should it. Because if it does, then all the boards are free game. Why does anyone need to do an OB/GYN residency if they can do FP with an OB fellowship? Why does anyone need to compete for a Derm residency if they can do FP with a Derm fellowship? Why can't an FP doc who does a Sports Med fellowship call himself an Orthopedist that just doesn't operate? Why can't the EM doc who does a CC fellowship sit for the ABIM board and also call themselves boarded in IM when they are done with the CC fellowship?
The US GME system isn't perfect, I'll acknowledge that, but I think if you weaken the individual boards and force them to recognize training in other specialties with tag on fellowships as equal training, then you will make the individual boards meaningless. ABEM means you did an EM residency and passed your boards. It doesn't mean that is the only way you can work in an ED. But it does meaning to it, and if that meaning is important to you, you should go through the proper channels to obtain it. If its not meaningful to you, then it shouldn't matter and you can go and do a fellowship and get ABMS certified.
Funding issues are usually not a big deal at most places. It is a commonly cited, but commonly misunderstood issue. TBH, the greater obstacle preventing people from applying to ACGME programs isn't that the program has to pay, it is that the attending IM/FM doc is going to have to get kicked back down to PGY-1 pay. By going to a non-ACGME accredited fellowship, they are not limited to the ACGME's resident pay structure.
The reality is that people who went IM/FM when they actually wanted EM is often because they were not competitive in their application year. Their inability to get an EM spot after graduation is usually not due to funding issues. It is true that there is a small handful of folks who realize too late that they simply chose wrong, but then we are back to the concept of protecting the specialty.
No program is going to go through the hassle of creating a 2.5 year fellowship. It would be easier for all parties to just go through a second residency. Also, just to be clear, the only reason prior grads from any specialty get 6m credit is because the PD is being kind.
Totally agree. Funding is not an issue at many places. Many hospitals are way over their GME allotted slots. We fund 50% of our ED resident slots through our budget. Its not as big of a deal as many would make it seem.
While I understand where you're coming from, this statement is patently false. I have yet to see an IM or FP resident or attending who is "more than qualified" to handle ALL OF the acute medical issues that roll though the ED. Can they handle anything that is medical floor-bound? Sure. How about the CHF septobomb who is failing BiPAP and requires emergent intubation and CVL placement? Procedural competency aside, outside of critical care IM docs, many of the IM attendings I've worked with have been very uncomfortable handling an unstable or crashing patient, even when compared to some some junior EM residents.
None of this is meant to bash IM/FP training. There is a laundry list of conditions that both fields can manage better than I ever will. That said, the implication that an IM/FP trained doc can handle the acutely decompensating medical patient as well as an EP is ludicrous.
Thank you both for your insight. You've both been very helpful. Just a man looking for answers...
If you don't mind, Let me pick your brains for just a few more minutes.
Lets say, "hypothetically speaking", that a PGY 1 or 2 resident in IM has an interest in Emergency Medicine. He did not truly get to experience EM until late in his 4th year of medical school and it was too late to apply. He would like to make the switch the best way possible. What is the best way for him to go about this? If funding is truly not that big of an issue, should he just go ahead and finish IM and get that board certification first instead of leaving his current residency program 1 resident short? Would this make him in the least bit more competitive when applying for the second residency? Or, should he just cut his losses, explain the situation to his PD, and apply for EM while he still has a year or 2 of full GME funding left. I know leaving a training program half way through can't look good. He is willing to finish current residency if needed. Maybe use all of his elective months to work in the ED? As far as his competitiveness, he was an average to slightly above average medical student with step scores of 235 and 240, partook in a handful of reputable extra-curricular activities, and has minimal research (a few case reports/poster presentations). Also, what about attempting to transfer into a local EM/IM residency? Do you think one of these options is more feasible/likely than the others? Greatly appreciate the input.
There are so many variables that are individual to each person, it is impossible to offer good advice over the webs. If you have an EM program at your institution, I'd speak to the PD about the logistics. Once you have those things figured out, I'd make friends the EM residents because they can make or break your application (although this probably varies with programs). If you do not have access to an EM program, you could consider cold-calling/emailing PDs or go to the residency fairs at ACEP and SAEM. At some point you need to tell your PD; depending on your relationship with them and their personality, they could very well offer a lot of help with this.
One day, I want there to be a collection of all the FM docs who post in the surgery forums saying they should be able to do surgeries after a 1-2 year fellowship. Or OB-GYN. Or anesthesia. Or literally any other specialty other than EM. Just like the alternate boards, they only exist so that medicine can continue to pretend that EM docs aren't a real group. Even PM&R, which is newer than EM, doesn't have this problem.
It makes me want to stab my eyeballs out.
Absolutely 100x what he said.
Talk to your PD. Explain that you are willing to finish out IM if you have to and explain your ultimate goal. Talk to the local EM PD if your hospital has one to get their advice. If someone only has a year left, Id just finish the last year out. Someone in their pG1 year, Id consider trying to jump ship and re-do the match if my PD was supportive. Just too many variables to give you exact advice.
Don't be devastated. If your program has a "low OB track" pick it so you can concentrate on other things.
Spend all your elective rotations in the emergency department.
There are plenty of FM trained physicians with experience working at lower volume EDs with the flexibility to do other things if they want. If you really want, you can do an EM fellowship.
Also: make use of your elective time. Get 2 rotations of icu and make the most of it. Try for a trauma surf rotation. While on surgical rotations, ask the anesthesiologist to tube the patients. Ask to work free weekends in the ED with good teachers.
If you really want EM that badly, you need to apply again, and to every program in the country. Period.
If you apply to every one, interview at every place you've been granted an interview at, and still get nothing, not even scrambling into an open spot, then you can be 100% proud you gave it your best shot.
But if you leave any open possibilities off the table, any program not applied to, any interview not gone to, any open spot offered not scrambled into, then you may regret it.
You can always turn down a spot if you match at the worst program in hell, but at least at that point, you're in the drivers seat, nobody else.
What you can't get back, is a match at a spot you never applied to, or interview you never went to.
The other option, of course, would be to conclude that maybe it's for the best, "everything happens for a reason," and such, and simply accept your current situation. (I can tell you, that shift work sleep disruption really is terrible).
But it's your life, your decision, that only you have to live with. Regardless, go with your gut, shoot for your dreams, and have no regrets.
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Why not just be a hospitalist with your FP training? Half the times my family has visited our local ED (large Level II) they have been seen by a hospitalist, 1 time was even a stroke. I also did EMS clinicals in a Level III Trauma/Chest Pain Center/Primary Stroke Center ER with around 20 bays/exam rooms and both MDs were originally trained in FM, although one was ancient so idk if EM residency was even an option for him back then. They did everything a boarded EM doctor would do, just maybe not multiple times per day but lac repairs were still pretty frequent. One was very approachable so I actually inquired a little bit about how she ended up an ER doctor and she told me she originally wanted to be a surgeon, but discovered it was "too tedious" and "nothing like MASH" so she wanted to do rural FM but found the ER job first and loved it and has been there for over ten years. She said in Medical School back then ER wasnt a required rotation and she "looked down on" those who wanted to go into EM. She was the nicest lady though, also did the most graceful and efficient chest pain interview I've ever seen. The ancient FM-Boarded ER Doc also had a medical student with him one day. One of the nights, the hospitalist came downstairs to the nursing station just to talk because it was slow upstairs and it was interesting to me how all three doctors were FM-trained 2 functioning as ER docs and 1 as a hospitalist.
I think actual real-world specialties and practice models outside of academic medicine are close to ABMS specialty descriptions but there's some deviation for sure hospital to hospital. Some board certified EM doctors won't even see major trauma at some places because the surgeons get them as soon as they come in the door which is an increasing trend.