Family Medicine and working in the ED

[Med201821]

Greetings,

I am not too familiar with the American medical system. I am also sure it varies state by state.

But if one were to pursue and complete a residency in family medicine or even internal medicine would they be able to work and pick up shifts in a hospital emergency room?

Where I am currently situated anyone can work in an emergency room. Unless you are fully certified in emergency medicine you will never be the "boss".

I am not interested in being a boss or expert in emergency medicine.

What I am interested in is being a FM doc or even IM and still being able to work ED. I love the environment, enjoy acuity but unfortunately I cannot see myself doing 30 + years of it.

It keeps you sharp though. My most significant learning experiences seem to always come from my shifts in ED and I would like to continue that.

So can anyone educate me on this? Are board certified IM or FM docs still able to do shifts in an ED? I know residents do rotations in ED if they are IM or FM.

Thanks in advance!

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[MedicineZ0Z]

Greetings,

I am not too familiar with the American medical system. I am also sure it varies state by state.

But if one were to pursue and complete a residency in family medicine or even internal medicine would they be able to work and pick up shifts in a hospital emergency room?

Where I am currently situated anyone can work in an emergency room. Unless you are fully certified in emergency medicine you will never be the "boss".

I am not interested in being a boss or expert in emergency medicine.

What I am interested in is being a FM doc or even IM and still being able to work ED. I love the environment, enjoy acuity but unfortunately I cannot see myself doing 30 + years of it.

It keeps you sharp though. My most significant learning experiences seem to always come from my shifts in ED and I would like to continue that.

So can anyone educate me on this? Are board certified IM or FM docs still able to do shifts in an ED? I know residents do rotations in ED if they are IM or FM.

Thanks in advance!

Most places want ABEM. If not, you should be a PA or NP. Can work autonomously in the ED with as a midlevel. (totally not kidding)

 

[Med201821]

FM - in some areas, yes. Generally board certified EM docs are preferred and so if you're somewhere where there are more than enough EM docs to go around, most likely you would not get hired. This is mostly accessible in rural areas and smaller cities.

IM - nope. They have no training in peds or OB, limited training in women's health and procedures like suturing, casting/splinting, etc., all of which are required to be able to function well in an ER.

Thanks. Much appreciated. I have no desire to live in an urban center although not keen for rural either but would do that before urban. Not sure my significant other would be though.

I know there are EM fellowships for FM grads. But obviously one should not bank exclusively on that if EM is what they truly want to do. I've heard from several people that EM is growing in popularity. Have not looked at the data to confirm that though.

I think IM can do crit care though. Although that is definitely not the same thing.

Most places want ABEM. If not, you should be a PA or NP. Can work autonomously in the ED with as a midlevel. (totally not kidding)

Well considering I am two months out from being an M4 I would say that ship has set sail. I enjoy acuity, I enjoy the pace, I enjoy the learning that happens in the ED. If I am unable to do it through FM or IM then that is a concession I am willing to make. Was just trying to see if I could have my cake and eat it haha.

 

[deleted87716]

IMO, if you want to do both, you should get boarded in both.

Dual Accreditation (EM/IM, EM/FM, EM/Peds) Emergency Medicine Applying Guide

Authors: Matthew Huang, MD, Brian Levine, MD, Pawan Suri, MD, Caitlin Schrepel, MD, Alexis Pelletier-Bui, MD on behalf of the CORD Advising Students Committee in Emergency Medicine (ASC-EM) This ap…

cordemblog.com

 

[deleted6669]

I know there are EM fellowships for FM grads. But obviously one should not bank exclusively on that if EM is what they truly want to do. I've heard from several people that EM is growing in popularity. Have not looked at the data to confirm that though.

FWIW, I know several folks who are FM physicians who either did EM fellowships or pursued the alternate board certification in EM. They work as ED medical directors at rural, critical access hospitals and are excellent physicians. That being said, none of them have been able to break into level 1 or 2 trauma centers, aside from working in the fast track areas. There are a number of FM physicians who work at level 1 and 2 places, but they have all essentially been grandfathered into those practices and when they retire they are being replaced by EM residency trained and boarded physicians. I echo the statement above from others: IF you want to do EM, train in EM. If you want to do EM and FM, train in both. The main competition for rural EM jobs isn't between EM and FM docs, it is between FM docs and PAs/NPs. If EM docs wanted those jobs and were willing to work for lower pay rates, they would get the jobs. I work at several rural, critical access hospitals that staff EM docs, FM docs, and PAs/NPs as solo, interchangeable providers. . The few EM docs get the top dollars(as they should), but the difference between the senior PA/NPs and the FM docs is less than 10% of the hourly rate with the docs getting slightly more in recognition of their MD/DO status, regardless of their skill level in EM. Something that the money folks take very seriously is that a PA/NP with 10+ years of experience in high level EM is likely a better EM provider than a generic FM physician, at a lower cost.

 

[MedicineZ0Z]

FWIW, I know several folks who are FM physicians who either did EM fellowships or pursued the alternate board certification in EM. They work as ED medical directors at rural, critical access hospitals and are excellent physicians. That being said, none of them have been able to break into level 1 or 2 trauma centers, aside from working in the fast track areas. There are a number of FM physicians who work at level 1 and 2 places, but they have all essentially been grandfathered into those practices and when they retire they are being replaced by EM residency trained and boarded physicians. I echo the statement above from others: IF you want to do EM, train in EM. If you want to do EM and FM, train in both. The main competition for rural EM jobs isn't between EM and FM docs, it is between FM docs and PAs/NPs. If EM docs wanted those jobs and were willing to work for lower pay rates, they would get the jobs. I work at several rural, critical access hospitals that staff EM docs, FM docs, and PAs/NPs as solo, interchangeable providers. . The few EM docs get the top dollars(as they should), but the difference between the senior PA/NPs and the FM docs is less than 10% of the hourly rate with the docs getting slightly more in recognition of their MD/DO status, regardless of their skill level in EM. Something that the money folks take very seriously is that a PA/NP with 10+ years of experience in high level EM is likely a better EM provider than a generic FM physician, at a lower cost.

You mean scamming the public.

 

[deleted6669]

You mean scamming the public.

No, I mean a a PA/NP with 10 years + of experience in high level EM runs circles around the vast majority of FM physicians who only work in a primary care clinic. The same FM doc certainly runs circles around that PA/NP for primary care issues. I have lots of respect for FM providers. They are experts at their field, and that field is family medicine.
It's just a matter of common sense. You are good at what you do every day. If you haven't intubated since residency, you will not be as good at it as someone who intubates several times a month and attends difficult airway cme and spends time in the OR practicing tubes on a regular basis. At my primary job, the hospital used to automatically credential all the FM physicians at the affiliated clinic to work in the ED. It quickly became apparent that most of them were not cut out for the work and the new EM contract a few years ago specifically removed most of them from the list of credentialed ED providers. We went from having 6-8 shifts a month covered by FM physicians to 1-2, and that last guy may lose his per diem status in this round of negotiations because a requirement for the per diem folks is that they work in EM elsewhere, and he doesn't.

 

[MedicineZ0Z]

No, I mean a a PA/NP with 10 years + of experience in high level EM runs circles around the vast majority of FM physicians who only work in a primary care clinic. The same FM doc certainly runs circles around that PA/NP for primary care issues. I have lots of respect for FM providers. They are experts at their field, and that field is family medicine.
It's just a matter of common sense. You are good at what you do every day. If you haven't intubated since residency, you will not be as good at it as someone who intubates several times a month and attends difficult airway cme and spends time in the OR practicing tubes on a regular basis. At my primary job, the hospital used to automatically credential all the FM physicians at the affiliated clinic to work in the ED. It quickly became apparent that most of them were not cut out for the work and the new EM contract a few years ago specifically removed most of them from the list of credentialed ED providers. We went from having 6-8 shifts a month covered by FM physicians to 1-2, and that last guy may lose his per diem status in this round of negotiations because a requirement for the per diem folks is that they work in EM elsewhere, and he doesn't.

1. Stop using the term "provider" to describe physicians.

2. Having an FM doc who has some additional training is what is ideal for settings without an ABEM doc. Hence the equivalent of what other countries do. Ever wonder how other countries get by doing better than USA without midlevels?

3. An FM doc with a little bit of experience/interest in EM would run circles around experienced ED midlevels. Trust me, I see the admits and garbage workups done by midlevels in the ED everyday. You're talking about procedural skills, I'm talking about inability of experienced midlevels to even rule out life threatening etiologies which is literally your main task. You're also comparing people who were forced to do ED work (that they very likely didn't want). What do you expect?

 

[deleted6669]

2. Having an FM doc who has some additional training is what is ideal for settings without an ABEM doc. Hence the equivalent of what other countries do.

3. An FM doc with a LOT of experience/interest in EM would run circles around MOST ED midlevels.

#2 We are in agreement. An FM doc who does a one year EM fellowship or has extensive EM experience makes for an excellent EM provider. My comments were in regards to FM docs doing EM without additional training.

#3 Fixed that for you.

 

[MedicineZ0Z]

#2 We are in agreement. An FM doc who does a one year EM fellowship or has extensive EM experience makes for an excellent EM provider. My comments were in regards to FM docs doing EM without additional training.

#3 Fixed that for you.

Whatever helps you sleep at night

 

[deleted6669]

Whatever helps you sleep at night

I sleep just fine.
Here's another thought for you: If you want to be called exclusively "Physicians" , stop calling PA/NP folks "midlevels". Call us PAs/NPs. You earned your title. I earned mine.

 

[Sardonix]

Whatever helps you sleep at night

Please stop being so confrontational about this. I am all for physicians fighting back against the crap national NP and PA organizations are pulling but you're delusional if you think an FM doc who does primarily outpatient and hasn't intubated since residency is more valuable in the ED than a PA with years of ED experience who does nothing but that each day. Should that PA still be supervised by a full fledged EM doc? 100%. Does an FM doc with minimal experience automatically outrank them because of their degree? In the FM office, sure. But in the ED experience and gestalt matter more than degree.

If your response to this is "Well you're part of the problem!" then by all means, please volunteer to let someone who hasn't intubated in years put in your ET tube next time you have a PTX or are being stabilize for airlift from Smalltown Hosp USA.

 

[SLC]

FWIW, I know several folks who are FM physicians who either did EM fellowships or pursued the alternate board certification in EM. They work as ED medical directors at rural, critical access hospitals and are excellent physicians. That being said, none of them have been able to break into level 1 or 2 trauma centers, aside from working in the fast track areas. There are a number of FM physicians who work at level 1 and 2 places, but they have all essentially been grandfathered into those practices and when they retire they are being replaced by EM residency trained and boarded physicians. I echo the statement above from others: IF you want to do EM, train in EM. If you want to do EM and FM, train in both. The main competition for rural EM jobs isn't between EM and FM docs, it is between FM docs and PAs/NPs. If EM docs wanted those jobs and were willing to work for lower pay rates, they would get the jobs. I work at several rural, critical access hospitals that staff EM docs, FM docs, and PAs/NPs as solo, interchangeable providers. . The few EM docs get the top dollars(as they should), but the difference between the senior PA/NPs and the FM docs is less than 10% of the hourly rate with the docs getting slightly more in recognition of their MD/DO status, regardless of their skill level in EM. Something that the money folks take very seriously is that a PA/NP with 10+ years of experience in high level EM is likely a better EM provider than a generic FM physician, at a lower cost.

The hourly pay at my rural emergency room is 3x higher for FM doc vs PA.

 

[deleted6669]

The hourly pay at my rural emergency room is 3x higher for FM doc vs PA.

As the senior EM PA in my group I make $10/hr less than the FM physicians and about 1/2 what the EM boarded guys make. The other PAs make $25/hr less.

 

[SLC]

As the senior EM PA in my group I make $10/hr less than the FM physicians and about 1/2 what the EM boarded guys make. The other PAs make $25/hr less.

All our PA’s make ⅓ what the docs make in the ER.

 

[deleted6669]

All our PA’s make ⅓ what the docs make in the ER.

Then you are underpaying your PAs. A good EM PA who is not a new grad should make 75-100/hr. If your docs make 300/hr, I apologize.

 

[SLC]

Then you are underpaying your PAs. A good EM PA who is not a new grad should make 75-100/hr. If your docs make 300/hr, I apologize.

We’re rural and critical access. Our PA’s make about $60/hr, docs...$200

 

[deleted6669]

We’re rural and critical access. Our PA’s make about $60/hr, docs...$200

Are those normal ranges for your area? New grad PA/NPs here make 65/hr doing outpt urgent care m-f 9-5. Rural doc rates in my neck of the woods for EM boarded docs run 150-250/hr. The FM docs make $100-110/hr.
Rural EMPAs generally make a lot more than typical PAs because that setting tends to draw the more experienced folks and the jobs are harder to fill.
Last year the "avg" EMPA with six years of experience made $124,100 yearly, which translates to 64.63/hr for a 40 hr week.

PA salary report 2021: Compensation impacts of the pandemic

The PA salary report provides a comprehensive overview of physician assistant compensation based on an AAPA survey of more than 14,000 PAs.

comphealth.com

Those with more experience make considerably more. I probably know over 100 EMPAs at this point and most make $75-100/hr with a few outliers making 125-150/hr for very remote positions and very long shifts(24-72 hr shifts). Short term locums positions can also pay very well like this one for $11,000 for one week:

Open Jobs - Wilderness Medical Staffing

wildernessmedicalstaffing.com

 

[SLC]

Are those normal ranges for your area? New grad PA/NPs here make 65/hr doing outpt urgent care m-f 9-5. Rural doc rates in my neck of the woods for EM boarded docs run 150-250/hr. The FM docs make $100-110/hr.
Rural EMPAs generally make a lot more than typical PAs because that setting tends to draw the more experienced folks and the jobs are harder to fill.
Last year the "avg" EMPA with six years of experience made $124,100 yearly, which translates to 64.63/hr for a 40 hr week.

PA salary report 2021: Compensation impacts of the pandemic

The PA salary report provides a comprehensive overview of physician assistant compensation based on an AAPA survey of more than 14,000 PAs.

comphealth.com

Those with more experience make considerably more. I probably know over 100 EMPAs at this point and most make $75-100/hr with a few outliers making 125-150/hr for very remote positions and very long shifts(24-72 hr shifts). Short term locums positions can also pay very well like this one for $11,000 for one week:

Open Jobs - Wilderness Medical Staffing

wildernessmedicalstaffing.com

I assume that’s a normal range for this area. Our ED PA’s all do 24hr shifts. The docs have only been willing to do 12’s. Most of the PA’s are 20+ years of experience, a few are fairly new. I will say, we have like 8 PA’s and 2 docs that work ER. I get crappily worked up folks pretty regularly, and our ED is unofficially known locally as a “lambing shed”. Our 2 FM guys that work the ED are trying to shape things up, but admin hasn’t exactly backed them up in it.

 

[MedicineZ0Z]

Please stop being so confrontational about this. I am all for physicians fighting back against the crap national NP and PA organizations are pulling but you're delusional if you think an FM doc who does primarily outpatient and hasn't intubated since residency is more valuable in the ED than a PA with years of ED experience who does nothing but that each day. Should that PA still be supervised by a full fledged EM doc? 100%. Does an FM doc with minimal experience automatically outrank them because of their degree? In the FM office, sure. But in the ED experience and gestalt matter more than degree.

If your response to this is "Well you're part of the problem!" then by all means, please volunteer to let someone who hasn't intubated in years put in your ET tube next time you have a PTX or are being stabilize for airlift from Smalltown Hosp USA.

I think we're comparing an FM doc who has an interest in EM (note, some rural docs do not - they're semi forced to do it) and has ongoing experience in it

 

[Med201821]

Thanks for clearing that up.

I think the clear answer is develop a way to time travel. Go back in time and become a NP or PA. Then troll SDN.

I just wanted to know if an FM certified doc could legally work in an ED. I think the answer is yes.

 

[deleted6669]

I just wanted to know if an FM certified doc could legally work in an ED. I think the answer is yes.

Correct. The take away point is that as an FM doc your emergency department employment options may be limited to smaller and/or rural departments.
(PS I am hardly a troll. I have been on this forum since 2001 and am supportive of my physician colleagues and partners, many who were born after I started my first job in the ED).

 

[Med201821]

Correct. The take away point is that as an FM doc your emergency department employment options may be limited to smaller and/or rural departments.
(PS I am hardly a troll. I have been on this forum since 2001 and am supportive of my physician colleagues and partners, many who were born after I started my first job in the ED).

Of course. Wasn't saying you were. Just being a bit cheeky. Appreciate the input. Thanks!

 

[Lexdiamondz]

Thanks for clearing that up.

I think the clear answer is develop a way to time travel. Go back in time and become a NP or PA. Then troll SDN.

I just wanted to know if an FM certified doc could legally work in an ED. I think the answer is yes.

As a physician your license to practise medicine is a license to practice all fields of medicine and surgery. As long as an institution is willing to credential you, you can essentially do anything you're comfortable with.

Generally, and FM doc can get a job in an ED in most rural and some suburban EDs, save for the ACS designated trauma centres (since those sites require BCEM, surgery and anesthesiology staff on site). These places often have difficulty retaining BCEM docs because of either low pay or poor working conditions, so they will hire whoever they can.

That being said, for the most part FM residency in US (and likely Canada as well) does not truly prepare you for the breadth of what is an Emergency Phsycians's scope of practice. You're basically practicing at your own (and at your patient's) risk.

 

[deleted6669]

FWIW, the hospital where I'm doing residency is a level 2 trauma center and we have at least two FM docs that I know of (both graduates of my program) working full time in our ER. Caveats: They have both been in practice for at least 15-20 years, we're in a smaller city surrounded by rural areas with the nearest level I centers being a 2-3 hr drive, and our program is known for full spectrum training

Agree with the rest of what you said though

Every trauma ctr I have ever worked at has had its fair share of FM docs as well. here's the thing: like in your situation, they had all been there for 20+ years. Every time they left for any reason they were replaced with a 30 yr old EM residency grad.