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FM and EM

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I'm an M4 at a US allopathic program. I did well on Step 1, waiting on Step 2, and am applying to EM in a week and a half.

After I finished my FM clerkship, I realized that I really enjoy outpatient FM. My concerns are basically whether the bread and butter would get to me before the bread and butter of EM would get to me, the difference in compensation, and whether the difference in occasional acuity would bother me enough to matter.

I've heard the EM side of the argument, but out of curiosity, I'd be interested in hearing from you guys who liked both and chose FM.
 

han14tra

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I'm an M4 at a US allopathic program. I did well on Step 1, waiting on Step 2, and am applying to EM in a week and a half.

After I finished my FM clerkship, I realized that I really enjoy outpatient FM. My concerns are basically whether the bread and butter would get to me before the bread and butter of EM would get to me, the difference in compensation, and whether the difference in occasional acuity would bother me enough to matter.

I've heard the EM side of the argument, but out of curiosity, I'd be interested in hearing from you guys who liked both and chose FM.

I'm in the same exact boat as you. I loved both. I'm probably choosing EM.

Things I don't like about outpatient FM:
1. You will still have call. Imagine working all day and coming home and getting 4 calls during the night. If you are in a group, it will probably only be 1-2x per week and 1 weekend a month.
2. Lower pay: $150,000 vs $240,000 in EM.
3. When you add in all the call, you'll most likely be working more hours in FM (~50 hrs/week compared to 40 in EM).

Things I don't like about EM:
1. Lifestyle- holidays, weekends, nights.
2. I don't really like critical care too much. I prefer healthy patients.

Some Qs to ask yourself:
1. Do you want true emergencies (MVAs, little old lady falls, cardiac arrest, stroke)?
2. Do you want procedures (central lines, intubations, chest tubes, splinting, suturing)? vs. joint injections and derm stuff in FM.
3. Do you want continuity (do you want to help someone manage their diabetes over years? Do you want to do well checks on kids every year?)
4. Do you want more chronic or more acute? Do you want the suicidal patient who comes to the ED for a crisis eval, or do you want the chronically depressed patient who comes in to the office for an antidepressent? Do you want the person with a BP of 220/110 and a headache, or do you want the patient who comes in for a check up with a BP of 160/90 and no symptoms? Do you want the little old lady who falls and breaks a hip, or do you want to help the family decide on whether she needs a nursing home?
5. Do you want immediate and routine CTs, X-rays, labs? Or, would you rather order a CT occasionally and get the result 2 days later?
6. Would you rather multi-task seeing numerous patients at once with a single complaint or manage multiple problems in the same patient?

If you can think of other things to consider, let me know because I still have a degree of uncertainty in the back of my mind.
 
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tiotropium

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Semi-rural FM: ER shifts if/when you feel like doing them, more procedures allowed than in an urban setting such as endoscopy (which we all know, procedures have higher reimbursement), nearly guaranteed patient pool (less competition), and higher reimbursement rates because it's rural. I hope to work for a rural health clinic attached to a hospital that will pay for the building, utilities, equipment, nursing/staff, maintenance, and still able to bill and receive the full reimbursement rate for my own patients rather than being on a hospital salary. Because it is rural and hospital based, I'm told that instead of billing ~$40 for a patient visit, the reimbursement is ~$120 per visit. Additionally, because the physician is not an employee, vacation days and work hours are set by the physician, not the hospital. There is call though and rural FMs generally round on their own patients. The flipside is that any critically ill patients or longer-term patients will get shipped to the nearest metro-hospital.
 
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smq123

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I think continuity of care, and how important it is to you, is really the fundamental question you have to ask yourself.

- Lifestyle is a little more predictable in FM than EM....you get most weekends off, as well as all holidays. Still, the number of hours per week is probably roughly the same, so it's a wash. Home call, especially if you don't have to do admissions for your practice, is pretty easy, generally speaking.

- Procedures are fun, but frequency of procedures is another question. Unless you work in a busy Level 1, you're probably not going to be doing chest tubes and intubations every night. In FM, the procedures are less glamorous, but if you want, you can be doing them 1-2 times a week.

I like feeling like I'm part of the community. To me, that's very important.
 

Smokemont

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I know nothing about either specialty but have worked other careers and my advice would be to remove salary from the equation. Money doesn't mean squat when you dread going to work.....everyday.......for the majority of your life.
 

tiotropium

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I know nothing about either specialty but have worked other careers and my advice would be to remove salary from the equation. Money doesn't mean squat when you dread going to work.....everyday.......for the majority of your life.

Very good point.
 

Frank Nutter

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Are there FM fellowships for EM, or vice versa?

I'm in a similar situation to the OP. Love the ED, but can see how I would come to hate it. Feel the opposite about FM...never really liked it, but it's growing on me. Ideally I would do both, about 50/50. Really don't care about the salary or lifestyle as much as nature of the work, autonomy and types of interactions. These fields overlap enough that I don't see why someone couldn't do both after a couple extra years of training.
 

smq123

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Are there FM fellowships for EM, or vice versa?

I'm in a similar situation to the OP. Love the ED, but can see how I would come to hate it. Feel the opposite about FM...never really liked it, but it's growing on me. Ideally I would do both, about 50/50. Really don't care about the salary or lifestyle as much as nature of the work, autonomy and types of interactions. These fields overlap enough that I don't see why someone couldn't do both after a couple extra years of training.

There aren't any FM fellowships for EM, as far as I am aware.

There are a few EM fellowships for FM. Not many, and they're generally in rural areas.
 

TPBC

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There aren't any FM fellowships for EM, as far as I am aware.

There are a few EM fellowships for FM. Not many, and they're generally in rural areas.

I know an EM physician that works in a Level 2 trauma center but also owns and operates a walk-in clinic staffed by a couple PAs or NPs. When he is not in the ED, he works in the clinic as well. I went there about six months ago for an URTI and he prescribed an antibiotic for me. So, apparently an EM physician can do FM?!?
 

smq123

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I know an EM physician that works in a Level 2 trauma center but also owns and operates a walk-in clinic staffed by a couple PAs or NPs. When he is not in the ED, he works in the clinic as well. I went there about six months ago for an URTI and he prescribed an antibiotic for me. So, apparently an EM physician can do FM?!?

That's urgent care, not FM.

Either EM or FM can do urgent care.
 

brats800

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On another note, we had a grad this past year from our FM program that, while a resident, got her ATLS in addition to her ACLS etc. She got hired working 24 hour shifts in a very rural ED (some urgent care / fast track stuff but also doing true emergency work). She is working a lot of nights / weekends / etc....

For me, I was in a similar thought process going into my MS4 year. The decision came down to that I didn't want to be working nights / weekends / holidays forever. I work (full time) 4 days per week 8-4 with a bit more when I do homecall or inpatient work. In my mind, you can't beat that even if I could probably get paid a bit more working in the ED.
 
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deleted19731

On another note, we had a grad this past year from our FM program that, while a resident, got her ATLS in addition to her ACLS etc. She got hired working 24 hour shifts in a very rural ED (some urgent care / fast track stuff but also doing true emergency work). She is working a lot of nights / weekends / etc....

Depending on where you go you can do this a resident. Im moonlighting at a rural ED and typically covering 12 and 24hr shifts. I'm just careful not to break work hours. I'm ACLS,ATLS,PALS,NRP, and ALSO as far as merit badges go but it really hasn't made a difference in finding ED work.

I've also been offered some shifts at a non rural ED but they see a lot of trauma and I'm going to wait until I have more experience. I'm thinking that its going to be my PGY III moonlighting gig since they pay substantially more than my current one.

For me, I was in a similar thought process going into my MS4 year. The decision came down to that I didn't want to be working nights / weekends / holidays forever. I work (full time) 4 days per week 8-4 with a bit more when I do homecall or inpatient work. In my mind, you can't beat that even if I could probably get paid a bit more working in the ED.

Agreed!!! This is why I chose FM. I especially like the opportunity for career flexibility. I'm currently looking for academic hospitalist positions after residency but it's very easy to slide into ED or clinic only jobs if you get bored with what you're doing. I also like that I have the ability to quickly specialize if I want (12 month fellowships). Hell if you want to do limited surgery it's a possibility (12mo surgical ob fellowships, 24mo proctology fellowship if you're a DO, and it looks like the AAFP is going to proceed with some type of GS fellowship geared for rural FM docs).

If you're a self-starter and like to work FM's a good career. The only people I know who think its a bad choice are other med students and residents who've never had a real job before...
 

ghost dog

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I'm an M4 at a US allopathic program. I did well on Step 1, waiting on Step 2, and am applying to EM in a week and a half.

After I finished my FM clerkship, I realized that I really enjoy outpatient FM. My concerns are basically whether the bread and butter would get to me before the bread and butter of EM would get to me, the difference in compensation, and whether the difference in occasional acuity would bother me enough to matter.

I've heard the EM side of the argument, but out of curiosity, I'd be interested in hearing from you guys who liked both and chose FM.


I found ER work to be very interesting as a medical student and resident, and planned on doing this at least part-time following my family practice residency. I did 7 - 8 months of ER rotations and 2 months of ICU electives for this purpose.

However, the weekends, shift work / nights, holidays, drunk /belligerent patients, drug seekers and other endless hassles that come with working as an ER attending lead me to reconsider this decision. In fact, the very issues that I found interesting as a student became aggravating as an attending.The practice of family medicine is much more conducive to career longevity and much less prone to burnout.

And like one of the above posters stated, money isn't everything, particularly when you're not happy with your chosen field. Besides,there are lots of opportunities to generate extra income in family medicine ( if you know were to look ).
 
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