family med vs. ED

[jok200]

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Okay... not trying to start any arguments just trying to figure stuff out.

Both are three years and both have interaction with med, peds, ob, psych so why would an ED resident be any more qualified in the ED than a Family doc that did ed electives during their residency? I understand the ED residency would have more exposure to procedures but even that can be learned by a family doc in the right residency?

-all this started as a discussion between some friends of mine.


thanks again-

 

[Rendar5]

Family Med isn't trained in how to take care of the crashing patient and spends less time working up the potential life threatening complications and conditions may face and more time working up the likely stuff.

I'll ask you this, how is a FM medicine trained to work up a tracheo-inominate fistula or realize when it's a possibility in the trach patient, how will they handle the patient coming in with BP 220/110 in acute pulmonary edema, what's their protocol for the syncopizing patient with massive hematemesis in hemorrhagic shock? work-up of an ectopic pregnancy? There's for more than a procedural difference in training.

It's no different than asking a EM what the current treatment protocols are for treating htn and dm as an outpt and when to adjust treatments. sure we have some idea of what to do and some basic training from med school and offservice rotation, but it's not what we're trained for or expert in.

 

[LastMinEMROLQs]

EMs are trained to treat the acutely sick (aka the crashing patient). In other words, EMs know what to do when **** hits the fan RIGHT NOW. I dont think FMs are comfortable with this just because its not the focus of their training and hence they don't have repetition with it.

An FM wouldn't know what to do on the spot in high acuity situations. They would jus kick that pt out of their clinic stat for a nice ambulance ride to the ED. Not hatin, jus sayin. 🙂

 

[docB]

Just look at the residency training. EPs spend much of second year and most of third year in the ED learning how to care for ED patients. FM residents spend much of second year and most of third year on the floors and in the clinic learning how to take care of inpatients and clinic patients.

EM is much more than FM and picking up some procedural skills on the side. Just as there's more to FM than running a clinic like I run my ED's fast track.

Decide what you want to do and train in it.

 

[Apollyon]

As someone said on the FM forum:

EM - acute generalists
FM - chronic generalists

Even if we chew some of the same ground, each side has many people that would never want to tread the waters of the other.

 

[BADMD]

Both are three years and both have interaction with med, peds, ob, psych so why would an ED resident be any more qualified in the ED than a Family doc that did ed electives during their residency?

Two EM residencies doesn't make me a trauma surgeon despite several months of SICU and trauma rotations, even if I go to the OR frequently. An EM residency doesn't make me competent to be a hospitalist. A couple of days of clinic doesn't make me competent to manage chronic diseases.

All of medicine has overlaps with other aspects. Often times it seems like we can do each others jobs. The dirty secret of medicine is that often we can. The key word being often. All those additional months of EM are what make me competent to work in the ED all of the time and not just most of the time. All that extra inpatient/outpatient/surgery are what makes other doctors competent to do their jobs all the time, not just most of the time.

 

[jok200]

Doc B, Apollyon and BADMD absolutely on point and informative in every way, completely made the distinction clear for me. Thanks for it I really was having difficulty seeing the difference but you guys really helped.

thanks -

 

[Braves123]

procedures is not exactly a small part of it.....I wouldn't want a fmp intubating me outta residency for sure even with a few months of extra anesthesia work under their belt, getting a central line from them.

EM is more like FM+ Anesthesia Critical Care (minus primary care IM)

 

[deleted109597]

EM is more like FM+ Anesthesia Critical Care (minus primary care IM)

Not really. EM is EM. Yes, it has the full breadth of birth to death that FM has, but that's about all it has in common with it. As above, FM is chronic management. Adding a second BP agent. HbA1Cs. EM is not.
I would argue that while EM does have some critical care, it is not a critical care specialty. We don't extubate people. We don't put in PEGs (initially, anyway). We don't trach people because they fail to extubate. We don't do TPN or tube feeds.

The only thing scarier than an FM doc trying to intubate is the IM guy trying to intubate a kid.

 

[pinipig523]

EM is EM and FP is FP. They do not cross well.

 

[jok200]

I completely agree that they are different in many ways, but that is primarily in the US. Many european countries don't even have emergency medicine as a residency because the general practioner(family doc) does that work. I personally like that their is a distinction between the two, as far as intubation goes Emergency med docs are a runner up in how to do it properly. I would prefer the anesthesiologist not the ED doc... the best analogy I have ever heard about an ED doc that is trained well is that the ED doc is not a black belt in any one thing but they are brown belts in everything. I think that sums it up for me.

 

[iridesingltrack]

I completely agree that they are different in many ways, but that is primarily in the US. Many european countries don't even have emergency medicine as a residency because the general practioner(family doc) does that work. I personally like that their is a distinction between the two, as far as intubation goes Emergency med docs are a runner up in how to do it properly. I would prefer the anesthesiologist not the ED doc... the best analogy I have ever heard about an ED doc that is trained well is that the ED doc is not a black belt in any one thing but they are brown belts in everything. I think that sums it up for me.

I disagree, we are black belts in EM. Every specialty has cross over with other specialties but EM, like gen surg, anesth, FM, IM etc, is its own unique specialty with its own unique knowledge and skill requirements.

iride

 

[goodoldalky]

I completely agree that they are different in many ways, but that is primarily in the US. Many european countries don't even have emergency medicine as a residency because the general practioner(family doc) does that work. I personally like that their is a distinction between the two, as far as intubation goes Emergency med docs are a runner up in how to do it properly. I would prefer the anesthesiologist not the ED doc... the best analogy I have ever heard about an ED doc that is trained well is that the ED doc is not a black belt in any one thing but they are brown belts in everything. I think that sums it up for me.

Obviously biased, but obviously disagree. For example, there is only one black belt in managing a crashing patient in AFib with RVR with a GCS of 7 who needs an airway and happens to have a pneumothorax, and a bleeding open femur fracture that needs stabilization prior to definitive management. Unless you can find an anesthesiorthocardiolosurgeon in house to handle it.

Other fields do part of what EM does. But only EM does EM.

 

[docB]

I completely agree that they are different in many ways, but that is primarily in the US. Many european countries don't even have emergency medicine as a residency because the general practioner(family doc) does that work. I personally like that their is a distinction between the two, as far as intubation goes Emergency med docs are a runner up in how to do it properly. I would prefer the anesthesiologist not the ED doc... the best analogy I have ever heard about an ED doc that is trained well is that the ED doc is not a black belt in any one thing but they are brown belts in everything. I think that sums it up for me.

I disagree vehemently. In my community setting our private practice anesthesiologists have not dealt with crash airways in decades (i.e. since residency) while I do it every day, several times. In my setting they are not comfortable with patients who have not been NPO or who have multiple acute, decompensating issues. I absolutely believe that for an ED airway and EP is the best.

EPs are the best, most appropriate physicians, black belts to use your term, to be treating patients in the ED. No one else can handle the gamut of what we see as well.

 

[Tiger26]

I completely agree that they are different in many ways, but that is primarily in the US. Many european countries don't even have emergency medicine as a residency because the general practioner(family doc) does that work. I personally like that their is a distinction between the two, as far as intubation goes Emergency med docs are a runner up in how to do it properly. I would prefer the anesthesiologist not the ED doc... the best analogy I have ever heard about an ED doc that is trained well is that the ED doc is not a black belt in any one thing but they are brown belts in everything. I think that sums it up for me.

In airway and resuscitation, we are the experts. My patient's aren't NPO with a pre-anesthesia medical evaluation documented in the chart

 

[RustedFox]

In airway and resuscitation, we are the experts. My patient's aren't NPO with a pre-anesthesia medical evaluation documented in the chart

This.

Just had a bad pneumonia/sepsis feller come in and refuse intubation several times until he tired out. When I asked him for the fifth time if he wanted to be tubed, he nodded out a tired "uh-huh".

Strange airway anatomy, too. Close shave, but doing just fine.

 

[Caric]

We interviewed a very bright 3rd year FM resident from one of the top FM residencies in the state for our residency program and he gave the best answer I've ever heard to this question. It involved a moonlighting experience he had where a little girl had been involved in some sort of tractor accident, and he was praying that EMS wouldn't bring her to his ED because he didn't know what to do. He said he wasn't applying to train in EM because he wanted the board certification or to improve his chances of working for a "competitive" group, but because he never again wanted to be in the position of hoping a patient would go somewhere else because he didn't know how to stabilize them. He loved working in the ED environment, but the fear in his voice was still almost palpable. If you want to do what's right for your patients, train in the environment where you'll be working.

 

[AlmostJesus]

I work in 2 hospitals where the FP physicians staff the ER. There is a noticeable difference in how the care is managed compared to when I did clinicals at a tertiary hospital. I think the FP physician can do a lot, but doesn't have the acute skills of an EM trained doc. For instance, they often delay intubating until anesthesia or the flight team comes (or I intubate them in the field).
I wish the training in acute care medicine would improve with family practice residencies, those doctors who are going to serve in rural areas are going to be staffing the ED, it would be nice to see them adding 1 year fellowships in rural ED medicine.

 

[mtwop]

We interviewed a very bright 3rd year FM resident from one of the top FM residencies in the state for our residency program and he gave the best answer I've ever heard to this question. It involved a moonlighting experience he had where a little girl had been involved in some sort of tractor accident, and he was praying that EMS wouldn't bring her to his ED because he didn't know what to do. He said he wasn't applying to train in EM because he wanted the board certification or to improve his chances of working for a "competitive" group, but because he never again wanted to be in the position of hoping a patient would go somewhere else because he didn't know how to stabilize them. He loved working in the ED environment, but the fear in his voice was still almost palpable. If you want to do what's right for your patients, train in the environment where you'll be working.

This 👍

The whole I idea that family med can "do it all" is a huge overstatement. They may be able to do everything, but that's far from being able to do everything well....same goes for ER docs or any other field of medicine

 

[Venko]

I do not want to repeat what is noted above, but I would like to add a point...

An off-service resident is not held to the same expectations as an on-service resident. Furthermore, as a resident progresses within their residency their expectations wtihin their own specialty are changed and their privileges change. Thus, 5 off-service rotations are not the same as 5 on-service rotations.

This is at least accurate in our institution.

For example, yesterday, two off-service residents and two on-service residents under my supervision in our resuscitation area. The third year EM resident is supervising all patients, reporting directly to me, running the code, choosing intubation drugs etc. The second year EM resident saw twice as many patients primarily, performed sedations, had intricate discussions about documentation, billing, and fine points of EM care. The off service residents saw a few patients a piece, had extremely close supervision by me, were working on differential diagnoses, and communication with patients.

If these residents do seven more rotations as an off service resident, I will not let them run the emergency department as I would the EM resident in his final year.
- They are not studying EM in the literature
- they are not studying EM in our didactic curriculum (no cadaver lab, Hand lab, Ultrasound lab, discussions of diagnositcs and resuscitations...)
- they are not bringing the mentality of how is this patient going to die under my watch to the shift
- they are not seeing as many patients as an EM resident is
- they are not aware of our protocols
- they are trying to learn what they can take back to their residencies and meld into their future goals (heme onc and neurology),
- they are cherry picking cases that may have some utility for their future
- they are asking everyone for guidance and working exceptionally hard, but are not learning the same things as an EM resident....

Off service rotation is no where near the same as an on service rotation...kinda like a medical student rotation is not the same as a chief resident on the same rotation...

FM and EM are not equivalent and interchangeable.

 

[TrumpetDoc]

I do not want to repeat what is noted above, but I would like to add a point...

An off-service resident is not held to the same expectations as an on-service resident. Furthermore, as a resident progresses within their residency their expectations wtihin their own specialty are changed and their privileges change. Thus, 5 off-service rotations are not the same as 5 on-service rotations.

This is at least accurate in our institution.

For example, yesterday, two off-service residents and two on-service residents under my supervision in our resuscitation area. The third year EM resident is supervising all patients, reporting directly to me, running the code, choosing intubation drugs etc. The second year EM resident saw twice as many patients primarily, performed sedations, had intricate discussions about documentation, billing, and fine points of EM care. The off service residents saw a few patients a piece, had extremely close supervision by me, were working on differential diagnoses, and communication with patients.

If these residents do seven more rotations as an off service resident, I will not let them run the emergency department as I would the EM resident in his final year.
- They are not studying EM in the literature
- they are not studying EM in our didactic curriculum (no cadaver lab, Hand lab, Ultrasound lab, discussions of diagnositcs and resuscitations...)
- they are not bringing the mentality of how is this patient going to die under my watch to the shift
- they are not seeing as many patients as an EM resident is
- they are not aware of our protocols
- they are trying to learn what they can take back to their residencies and meld into their future goals (heme onc and neurology),
- they are cherry picking cases that may have some utility for their future
- they are asking everyone for guidance and working exceptionally hard, but are not learning the same things as an EM resident....

Off service rotation is no where near the same as an on service rotation...kinda like a medical student rotation is not the same as a chief resident on the same rotation...

FM and EM are not equivalent and interchangeable.

VERY well stated!

And of course the turn around is true too...and all are happy 🙂


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