Family medicine to EM

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How common is it to see family medicine trained ER physicians in the real world? I know they exist but, do they sequester these physicians into rural areas or are they allowed to work in big cities too?

 

[RustedFox]

One is "allowed" to work anywhere they can get a job - but not many FP trained docs are going to be hired by a place with (any) acuity.

 

[ActionFigure]

One is "allowed" to work anywhere they can get a job - but not many FP trained docs are going to be hired by a place with (any) acuity.

Even if the FP trained doc does a fellowship in Emergency Medicine?

 

[RustedFox]

Pretty much yes. This topic comes up pretty regularly on here, and the answer is always the same. I know the forum search function on here is far from the best (the same engine runs another hockey board that I post on, and it sucks there, too) - but a search on this will get you a lot more.

 

[Aces]

I would definitely recommend any FP trained doc who wants to practice EM, even in a low volume setting, to get a year of an EM fellowship if possible.

I've been practicing EM in rural areas for a couple years now, since my graduation from an FM program (we trained in a large 100K ED volume, Level 1 Trauma and did tons of moonlighting and rotations in ED, Trauma, Anesth, Ortho)
. There are some ED groups that offer a short fellowship and you should look into that.

The fact of the matter is that there are not enough EM Residency Trained, Board Certified physicians out there at this time. There might be enough in about a decade or two, but for now be prepared to travel to rural EDs for shifts.

Obviously and ultimately if you want to practice a certain medical specialty, you should do a residency in that field.

 

[Tiger26]

If you want to do EM, do an EM residency.

I'm not walking up to the OR tonight to moonlight as a general surgeon because I did the rotation in med school and spent a bunch of time in the SICU in residency.

Nor am I opening up a family medicine clinic and moonlighting in family medicine stuff.

The end.

 

[dotcb]

How common is it to see family medicine trained ER physicians in the real world? I know they exist but, do they sequester these physicians into rural areas or are they allowed to work in big cities too?

You should understand that those of us that did a residency in EM and are board certified in the field find this analogous to us saying:

"I know how to manage airways and sedate patients, can I just do a 1 year anesthesia fellowship and be a practicing anesthesiologist?"

"I do a lot of procedures, can I do a 1 year general surgery fellowship and be a surgeon?"

"I know how to do deliveries and know a lot about womens' health, can I do a 1 year Ob fellowship and practice?"

This kind of thing might fly in the developing world and where there is no doctor. For the developed world, if you care enough to be good at your specialty - train in it.

 

[Aces]

You have to remember that the fathers of EM were board certified primary care trained doctors. There's overlap between the 2, but I wouldn't recommend redoing a residency to do EM if one can do a year of a fellowship in a solid level 1 trauma center. In addition make sure to get acls atls pals/apls . I would even recommend fundamentals of critical care and ultrasound courses.

If one masters those and can effectively practice, then you should be on a safe level.

I know that EM trained doctors hate it that others who didn't do training in EM can practice safely and competently with the above being done.
It's job security for them to insist otherwise, but fact if the matter is more than 1/3 of EM docs are not residency trained.

You should understand that those of us that did a residency in EM and are board certified in the field find this analogous to us saying:

"I know how to manage airways and sedate patients, can I just do a 1 year anesthesia fellowship and be a practicing anesthesiologist?"

"I do a lot of procedures, can I do a 1 year general surgery fellowship and be a surgeon?"

"I know how to do deliveries and know a lot about womens' health, can I do a 1 year Ob fellowship and practice?"

This kind of thing might fly in the developing world and where there is no doctor. For the developed world, if you care enough to be good at your specialty - train in it.

 

[deleted109597]

You have to remember that the fathers of EM were board certified primary care trained doctors. There's overlap between the 2, but I wouldn't recommend redoing a residency to do EM if one can do a year of a fellowship in a solid level 1 trauma center. In addition make sure to get acls atls pals/apls . I would even recommend fundamentals of critical care and ultrasound courses.

Because there wasn't a way to train in EM. The fathers of EM also saw what was going on was unsafe and wanted to change it so the training was designed to work in the ED, not the jackassed workaround you're discussing.

If one masters those and can effectively practice, then you should be on a safe level.

I know that EM trained doctors hate it that others who didn't do training in EM can practice safely and competently with the above being done.
It's job security for them to insist otherwise, but fact if the matter is more than 1/3 of EM docs are not residency trained.

Very few of the people who don't do training can do it safely and competently. Sure, they can pretend, and in places with relatively low acuity, get by, but when the **** hits the fan, they don't know what to do.

 

[Arcan57]

You have to remember that the fathers of EM were board certified primary care trained doctors. There's overlap between the 2, but I wouldn't recommend redoing a residency to do EM if one can do a year of a fellowship in a solid level 1 trauma center. In addition make sure to get acls atls pals/apls . I would even recommend fundamentals of critical care and ultrasound courses.

If one masters those and can effectively practice, then you should be on a safe level.

I know that EM trained doctors hate it that others who didn't do training in EM can practice safely and competently with the above being done.
It's job security for them to insist otherwise, but fact if the matter is more than 1/3 of EM docs are not residency trained.

There are many docs that think they can do (or are doing) our jobs as well as we do. In places that have a choice, non ABEM boarded/BE docs aren't employed unless they've been in practice as an EM doc for forever. Essentially you're making the same argument that the militant NP's make, which is sort of ironic.

 

[Tiger26]

You have to remember that the fathers of EM were board certified primary care trained doctors. There's overlap between the 2, but I wouldn't recommend redoing a residency to do EM if one can do a year of a fellowship in a solid level 1 trauma center. In addition make sure to get acls atls pals/apls . I would even recommend fundamentals of critical care and ultrasound courses.

If one masters those and can effectively practice, then you should be on a safe level.

I know that EM trained doctors hate it that others who didn't do training in EM can practice safely and competently with the above being done.
It's job security for them to insist otherwise, but fact if the matter is more than 1/3 of EM docs are not residency trained.

Complete fallacy of logic. So because Hippocrates was the documented father of all things medicine, then anyone can do any specialty because we're all derived from a generalist?

 

[vistaril]

Even if the FP trained doc does a fellowship in Emergency Medicine?

To me as an outsider 4 years of total training(with all 4 years being relevant to most ER work) with the final year being exclusively in the ER working in an EM fellowship > 3 years total training with ~70-75%(?) of it in the ER and the rest on services that would in many cases overlap with the same off service rotations a family med resident does.

 

[HankReardon]

all 4 years being relevant to most ER work

Trying to massage relevancy into actual training is laughable. I appreciate your opening caveat of being an outsider, but it doesn't excuse the ignorance. I'd be interested to hear how you had developed your assessment.

While a FM physician could more than adequately handle the 70-80% of primary care cases that walk through the door, those cases aren't where the men are separated from the boys. It's that 10-20% of very sick to crashing patients that are the difference. The ones that the FM residents don't manage during their ED rotation. Similarly, I would bog the hell down titrating a basal/bolus insulin regimen, algorithm'ing an abnormal pap smear or reminding you when you should get your next screening colonoscopy (actually, I'm not too far away from floor rotations so I could knock that insulin regimen out in my sleep). The only difference I would suggest is that if I were working your clinic and had to stop and consult Dr. Google to treat your sickest patient today, he would be pissed off at the wait. If you did the same to my sickest patient today, he would be dead.

Steps on one ladder certainly seem relevant to steps on another ladder, but your 7ft ladder ain't going to cut it for my 10ft roof.

 

[RustedFox]

Nearly 100% of my patients have HTN, DM, and hyperlipidemia. Does that make me an expert in managing them because "I've seen it" for three years of residency ?

 

[DeadCactus]

I've got ATP3 and JNC7 on my iPhone. Brb, opening a family medicine clinic...

 

[Apollyon]

Trying to massage relevancy into actual training is laughable. I appreciate your opening caveat of being an outsider, but it doesn't excuse the ignorance. I'd be interested to hear how you had developed your assessment.

While a FM physician could more than adequately handle the 70-80% of primary care cases that walk through the door, those cases aren't where the men are separated from the boys. It's that 10-20% of very sick to crashing patients that are the difference. The ones that the FM residents don't manage during their ED rotation. Similarly, I would bog the hell down titrating a basal/bolus insulin regimen, algorithm'ing an abnormal pap smear or reminding you when you should get your next screening colonoscopy (actually, I'm not too far away from floor rotations so I could knock that insulin regiment out in my sleep). The only difference I would suggest is that if I were working your clinic and had to stop and consult Dr. Google to treat your sickest patient today, he would be pissed off at the wait. If you did the same to my sickest patient today, he would be dead.

Steps on one ladder certainly seem relevant to steps on another ladder, but your 7ft ladder ain't going to cut it for my 10ft roof.

That person (vistaril) is a psych resident, and he is frequently at odds (sometimes quite vehemently) with other people in the psych forum.

 

[SeekerOfTheTree]

I stayed at a Holiday Inn, can I be a Family Medicine doctor?

 

[knovecc]

In Canada, vast majority of Emerg docs are FM+EM or bare FM docs picking up emerg shifts.
even in tertiary trauma centres, only half of the emerg docs are 5-year EM specialty trained (FRCP)
in smaller hospitals, even the ones in big cities, you can hardly find any "proper" EM specialist docs

 

[Apollyon]

In Canada, vast majority of Emerg docs are FM+EM or bare FM docs picking up emerg shifts.
even in tertiary trauma centres, only half of the emerg docs are 5-year EM specialty trained (FRCP)
in smaller hospitals, even the ones in big cities, you can hardly find any "proper" EM specialist docs

I am not sure how "respected" the CCFP-EM route is (for those not knowing, that is doing a "full" FM program - which is 2 years - then one more year of EM, dedicated). It seems that the 5yr FRCP EM programs have the CCFP-EM folks side by side, with full commingling. When I say "respected", I have no pejorative or dismissive intent. I simply don't know if equal is equal, in the eyes of Canadian practitioners.

 

[SoCuteMD]

You have to remember that the fathers of EM were board certified primary care trained doctors. There's overlap between the 2, but I wouldn't recommend redoing a residency to do EM if one can do a year of a fellowship in a solid level 1 trauma center. In addition make sure to get acls atls pals/apls . I would even recommend fundamentals of critical care and ultrasound courses.

If one masters those and can effectively practice, then you should be on a safe level.

I know that EM trained doctors hate it that others who didn't do training in EM can practice safely and competently with the above being done.
It's job security for them to insist otherwise, but fact if the matter is more than 1/3 of EM docs are not residency trained.

They can? As a blanket statement. Prove it - show me the literature.

To me as an outsider 4 years of total training(with all 4 years being relevant to most ER work) with the final year being exclusively in the ER working in an EM fellowship > 3 years total training with ~70-75%(?) of it in the ER and the rest on services that would in many cases overlap with the same off service rotations a family med resident does.

At the end of the day, FM residency is very different from EM residency. Clinical experience does not encompass all that is residency and I'd venture to say that any FM residency in which "all" of residency is relevant to EM is egregiously neglecting the mission of family medicine as I understand it.

 

[TPBC]

They can? As a blanket statement. Prove it - show me the literature.



At the end of the day, FM residency is very different from EM residency. Clinical experience does not encompass all that is residency and I'd venture to say that any FM residency in which "all" of residency is relevant to EM is egregiously neglecting the mission of family medicine as I understand it.

Just a thought, EM folk should probably embrace some of these FM trained ED docs because if enough EM attendings are trained to occupy 100% - or more - of EM positions, many EM docs currently working high acuity centers will be pushed out to lesser desirable rural locations because "better" EM docs with more recent training, higher scores, or training at "better more pretigious" centers, etc. will be working be working these more desirable areas. The argument will be the same as the EM vs. FM argument: patient safety - the better the training, the better outcome for the patient. Also, probably a more crucial issue for EM physicians, the more EM docs trained (and especially if there is a surplus), the higher the chance that salaries will plummet.

 

[racerwad]

Just a thought, EM folk should probably embrace some of these FM trained ED docs because if enough EM attendings are trained to occupy 100% - or more - of EM positions, many EM docs currently working high acuity centers will be pushed out to lesser desirable rural locations because "better" EM docs with more recent training, higher scores, or training at "better more pretigious" centers, etc. will be working be working these more desirable areas. The argument will be the same as the EM vs. FM argument: patient safety - the better the training, the better outcome for the patient. Also, probably a more crucial issue for EM physicians, the more EM docs trained (and especially if there is a surplus), the higher the chance that salaries will plummet.

Why would you want to resist better, more thorough training just so that the average stays low? That doesn't make sense at all. You're also assuming that the most ambitious, best trained persons will want to go to the most "prestigious" centers but perhaps they just want to maximize their options on the open job market.

 

[e30ftw]

(...) ...if enough EM attendings are trained to occupy 100% - or more - of EM positions, many EM docs currently working high acuity centers will be pushed out to lesser desirable rural locations because "better" EM docs with more recent training, higher scores, or training at "better more pretigious" centers, etc. will be working be working these more desirable areas.

The number of EM trained physicians is currently grossly inadequate to meet demand and even with the slight increase in residency graduates the amount of ABEM physicians retiring negates gains. I would be very happy with ABEM physicians working in more community hospitals as honestly I think it would be beneficial both for patient safety and ED flow/consultants/EMS/US/etc. Salary depends more on healthcare at the federal level, population demographics, and group pay structure than individual credentials. from what i hear a lot of the best EM jobs are in suburban median acuity community EDs run by an efficient group so I would be perfectly fine working in an access hospital outside a major metropolitan area.

 

[TPBC]

Why would you want to resist better, more thorough training just so that the average stays low? That doesn't make sense at all. You're also assuming that the most ambitious, best trained persons will want to go to the most "prestigious" centers but perhaps they just want to maximize their options on the open job market.

You misunderstood what I said - I am on your side - I think all EDs should be staffed by EM BC physicians (ABEM or ABOEM), however, increasing the number of residencies to provide 100% coverage may have some unintended consequences. That said, what percentage of patients that come to the ED are truly in need of a EM physician? Maybe instead of employing midlevels in secondary positions, why not consider employing some IM/FM docs who truly want to work in the ED or, instead of three EM trained docs on a shift, schedule two EM docs with one IM/FM docs (more profit for the corporation!). The EM docs could treat the truly emergent patients. Anyway, I believe it pays to be open minded about this. A short time ago, docs felt that all patients should be treated only by physicians and look was happened (the midlevel issue)! But yes, with all others matters equal, I am all for EM trained docs in the ED.

 

[Arcan57]

Just a thought, EM folk should probably embrace some of these FM trained ED docs because if enough EM attendings are trained to occupy 100% - or more - of EM positions, many EM docs currently working high acuity centers will be pushed out to lesser desirable rural locations because "better" EM docs with more recent training, higher scores, or training at "better more pretigious" centers, etc. will be working be working these more desirable areas. The argument will be the same as the EM vs. FM argument: patient safety - the better the training, the better outcome for the patient. Also, probably a more crucial issue for EM physicians, the more EM docs trained (and especially if there is a surplus), the higher the chance that salaries will plummet.

That's quite the fail from a logic standpoint. The EM people that want to live in big cities (and there are a lot of them) have already made those markets tough to break into with the resultant decrease in salary, etc. FM fellowship trained docs don't just work in critical access hospitals, and by claiming to be board certified in EM theoretically compete with EM trained physicians for those same city jobs. There is a legitimate problem with inadequate training for non-EM trained emergency practitioners in critical access hospitals and I think the fellowship helps with that, but I don't think it provides equivalence to an EM trained doc.