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FM/EM vs. FM w/ EM fellowship

Discussion in 'Emergency Medicine' started by BSEMD, Jul 20, 2006.

  1. BSEMD

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    To all: Before you (over)react, please understand where I'm coming from. I will be an M1 this fall, and have only inklings as to what I want out of my career. As such, I like to weigh and compare career options, regardless of specialty, whenever possible (ie, which specialty has the potential to offer substantial family life; which specialty will protect me from professional boredom, etc, etc, etc...).

    There is an emergency medicine fellowship, for those who are BC in FM (several, actually), which lasts for 1-2 years, leading to a specialty certificate (not BC/BE status) in Emergency Medicine. My gut tells me that while this may be an acceptable way to supplement the FM education and become MORE prepared to work in the ER at a smaller/rural ED, there is/will be a movement to keep those physicians who aren't BC/BE in EM OUT of EM jobs.

    I've had an inkling that EM may provide for me the variety and pace that I would enjoy in my career as a physician; however, I also feel that I may enjoy the simpler side of things (ie, outpatient practice, continuity of care, etc.)...hence my curiosity.

    Recently, I read that there now exists a FM/EM combinded residency program, which lasts 5 years. Is this the only legitimate way to accomplish the goal of providing a professional life that encompasses both EM and FM, or are there any students who are pursuing the FM residency with EM fellowship?

    Thanks to all who wish to weigh in on this topic!
     
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  3. SoCuteMD

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    My feeling is that the openings for FM boarded doctors in EDs are on the decline. EM is still a relatively new specialty, and I think many of the original EM boarded physicians are still practicing and will be for another 10 years or so (sorry BKN...you aren't a dinosaur yet). As a result, the total # of EM physicians is on the rise. Couple that with new residency programs and the field is expanding even more.

    In summary, if I wanted to work in an Emergency Department I would probably not feel like being FM boarded, even with an EM fellowship, would give me enough job security in the ED. Obviously if you are FM boarded you will have other options.

    Just my $0.02, not worth even that much since I'm only entering MS2.
     
  4. DropkickMurphy

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    If you want to work in an ED, do an EM residency. If you want to be an FP doc and pretend to be a EM doc in your spare time, volunteer as a paramedic somewhere. :laugh:
     
  5. Blue Dog

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    The schedule and work environment of emergency medicine and family medicine really are worlds apart. You owe it to yourself to figure out which one you prefer, and go after that. I started med school with the same thoughts...I liked the idea of being a generalist, and was initially drawn to emergency medicine because of my experience as a volunteer EMT. Eventually, I realized that I preferred the controlled schedule, regular hours, and continuity of care of FM to the chaotic shiftwork and episodic care of EM. Most EM folks thrive in that environment, however. If you're considering rural medicine or urgent care, the combined FM/EM residency makes some sense. Otherwise, I think you're better off going EM if you want to work in an ED, and FM if you want to work in primary care.
     
  6. southerndoc

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    Many hospitals and malpractice insurers now insist that emergency physicians be board-certified in emergency medicine. As of right now, ABEM only allows residency-trained individuals to sit for the board exam.

    An EM fellowship will not get you boarded in emergency medicine. It is likely that the trend toward hiring only EM-boarded or board-eligible physicians will continue. Therefore, I suggest if you want to do EM, you actually do a residency in EM.
     
  7. 8744

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    Hell, why do a two year fellowship that will leave you with nada (in terms of board certifiability) when you could do one year more and get the whole enchilada?

    I also understand that several dual FM/EM programs are in the works that would allow board certification in both specialties.
     
  8. 8744

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    Listen to your gut.
     
  9. BKN

    BKN Senior Member
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    The pathway has been approved. As of now, I don't believe there have been applications to the Boards to set up such programs. It's early times, but there seems to be significant resistance among the EM program directors. A lot of us think we need more plain EM slots.
     
  10. DrMom

    DrMom Official Mom of SDN
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    A resident in my EM program completed a FM residency followed by an EM fellowship. It left him with limited job prospects, so now he's doing 3 years in an EM residency.
     
  11. BSEMD

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    Wow...I never thought that this would be the case. I suppose that I foresaw a fellowship opening doors, though it seems for this person that the doors were not opened very wide. It's a big decision (I presume) for a doctor who has already completed their residency and entered professional life to leave the prospects of said professional life to return to the grueling pace of a residency. Did he at least get some credit for his previous residency (I've read on various threads throughout SDN that at MOST 6 months is given, at the discretion of the program itself)?

    Thanks for taking the time to reply DrMom...much appreciated!
     
  12. BSEMD

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    This is probably the best advice that I could get on the matter...if my gut is telling me that working in the ED is the way to go, perhaps I should just go for it, instead of picking a different path and trying to side-step my way into it.

    Thanks for the thoughts on the matter PandaBear. :thumbup:
     
  13. DrMom

    DrMom Official Mom of SDN
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    Well, he'd already done 4 years of training...he got a year credit in the EM program. We're a 4 year residency, but he'll have done 7 years by the time he finishes.
     
  14. BKN

    BKN Senior Member
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    OP, note that Mom is speaking of a DO em residency.

    The six month maximum comment applies to allopathic residencies. And it's only partly at the discretion of the EM PD. When I take such a person, I tell them that I will do my best for them. I review their previous training, specify up to 6 specific training months to be forgiven and justify each month. The Board then decides. They're pretty strict.
     
  15. DrMom

    DrMom Official Mom of SDN
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    Good point. They basically credited him the internship year, but that would be different in an MD program.
     
  16. Squad51

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    In an allopathic 2-3-4 program (e.g., Cook County), they would likely waive the "intern" year as well on the presumption that, in completing a ACGME accredited residency program, he/she de facto successfully completed an intern year...

    right BKN?

    :cool:
     
  17. BKN

    BKN Senior Member
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    Yes, but if he has two years of ACGME accredited training within the last 60 months he can go for the half year credit as well. The ABEM considers PG1-3 and PG 2-4 as the same format, EM1-3.

    In either format he would need 2.5-3 years to finish training. If he matched at a EM1-4, he would need 3.5-4 years.
     
  18. irrka

    irrka Senior Member
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    wait, wasn't there some sort of a combined FM/EM thing in Kentucky?
     
  19. Squad51

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    Yes, there is a EM fellowship for FPs. However it does not lead to ABEM certification, so it really is of limited use. It will NOT allow an FP to get BE/BC only jobs, nor is it likely to protect their job should an EM group come to town...

    :cool:
     
  20. Derek

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    Taken from ABFM website.

    ABFM AND ABEM ANNOUNCE COMBINED TRAINING PROGRAM
    Friday, March 24, 2006 The American Board of Emergency Medicine (ABEM) and the American Board of Family Medicine (ABFM) have approved guidelines for a five-year combined training program that, upon completion, will provide graduates the opportunity to seek certification in both Emergency Medicine (EM) and Family Medicine (FM).

    In 2005, ABEM and ABFM initiated discussions that focused on the interface between EM and FM. The boards recognized that as the practice of medicine is rapidly changing there may exist the opportunity to develop new training options for individual physicians and improve care for patients.

    James C. Puffer, M.D., President and Chief Executive Officer of the ABFM, sees the new opportunities for combined EM and FM residencies as progress toward fulfilling future manpower needs in Medicine. "In creating this combined program, both Boards envisioned opportunities to improve the quality of care delivered to the American public in every Emergency Department in the United States, to provide a training pipeline for physicians who had a strong desire to situate themselves in areas of health manpower need, and to develop a cadre of well-trained physicians who would serve as the unique interface between Departments of Family Medicine and Emergency Medicine within Academic Health Centers and community hospitals across the country," says Dr. Puffer.

    Both boards identified six months of redundancy in the EM and FM training requirements while assuring that EM and FM requirements would be met. Combined programs will include components of categorical EM and FM residencies that are accredited respectively by the Residency Review Committee (RRC) for EM and the RRC for FM, both of which function under the auspices of the Accreditation Council for Graduate Medical Education (ACGME). Combined programs will be approved by ABEM and ABFM, with each categorical program being accredited by their respective RRC.

    The objectives of this combined training include preparing physicians for practice or academic careers that address the spectrum of patient illness and injury from emergency situations through the total health care of the individual and the family. Graduates of the combined training program may function as generalists, practice either or both disciplines, enter subspecialty training programs approved by either Board, or undertake research. Within an institution, their perspectives derived by spanning the two specialties have the potential to increase communication and understanding.

    ACGME-accredited EM and FM residencies interested in developing an Emergency Medicine/Family Medicine combined training program should contact either ABEM or ABFM for an application packet. The completed application material must be submitted to both boards for review, and both boards must approve the program before the program enrolls residents.

    Upon successful completion of the combined training program, a resident must submit the appropriate applications to ABEM and ABFM to enter the certification process. The guidelines for this combined training program in EM and FM, are available in a downloadable PDF format:

    Guidelines for Combined Residency Training in Emergency Medicine and Family Medicine

    It is the position of ABEM and ABFM that combined training in EM/FM is the sole recognized pathway for EM residents to train in FM and the sole recognized pathway for FM residents to train in EM, other than completion of both categorical EM and FM residency programs accredited by the ACGME.
     
  21. Derek

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    Taken from AAFP website:

    3/29/2006



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    It's likely medical students soon will have the option of matching to combined family and emergency medicine residency programs as a result of guidelines (PDF file: 6 pages / 32.1 KB. More about PDFs.) recently approved by the American Board of Family Medicine and American Board of Emergency Medicine.



    Mark Belfer, D.O., left, family medicine residency program director at Akron (Ohio) General Medical Center, and Elliott Davidson, M.D., medical director of the medical center's family medicine center, discuss residency training issues, including combined family and emergency medicine programs. The guidelines, announced by ABFM and ABEM March 24, allow hospitals and other residency sponsors with accredited programs in family and emergency medicine to offer combined residency training that leads to dual board certification. Programs could launch combined residency training programs as early as July.

    When first discussed in 2005, 72 family medicine residency programs expressed interest in offering this type of dual training, according to Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education. He expects at least three or four programs to launch dual training in 2006.

    Dual family and emergency residency training is a resource for residents who plan careers that combine family and emergency medicine, such as in rural practices where family physicians often staff emergency departments, said Pugno.

    The dual residency approval will help preserve family physicians' role in emergency departments, ensure medical coverage of EDs in underserved areas and address emergency medicine's desire for board-certified ER directors, according to Mark Belfer, D.O., director of the family medicine residency program at Akron General Medical Center in the Northeastern Ohio Universities College of Medicine hospital consortium. Belfer served on the AAFP Commission on Education during the ABFM-ABEM discussions.

    "The reason (these guidelines) came about was because several family physicians in rural areas were getting shut out of emergency rooms where they'd been working for years," he said. "ABEM's goal is to have all emergency rooms staffed by board-certified emergency medicine doctors."

    The guidelines stipulate that graduates of combined training programs can sit for certification in each specialty and practice as family physicians, emergency medicine physicians, or both. They also can enter subspecialty training programs approved by either board or undertake research.

    Approved programs must provide 30 months of training under the direct supervision of each specialty, according to the guidelines, for a total of 60 months of training. Six months of training should be provided under each specialty in the first year. Continuous assignments in one specialty should not be less than three months or more than six months in that specialty.

    "The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations between the two specialties," the guidelines say. "Duplication of clinical experiences between the two specialties should be avoided."
     
  22. Squad51

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    BKN,

    Wasn't there some big blow-up as well? Wasn't there some agreement reached that the AAFP would take a stronger position that EM was it's own specialty and they have, instead, continued to maintain that FPs can safely do EM without additional training?

    I thought I read that in one of the throw-aways...

    :cool:
     
  23. Blue Dog

    Blue Dog Fides et ratio.
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    Here is the AAFP Position Paper on Emergency Medicine: http://www.aafp.org/online/en/home/policy/policies/e/emergencymedicinepaper.html

    Here are the guidelines for dual FM/EM residency programs: http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20060329guidelines.html
     
  24. Squad51

    Squad51 Paracelsus'es Love Child
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    I believe the line in question is: "It is also well established that emergency care is within the scope of family medicine." If I remember the article correctly, there was an agreement to remove this from their position paper, which they reneged on.

    Did anyone else read this or am I imagining it?

    :cool:
     
  25. BKN

    BKN Senior Member
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    I'm not sure. From my viewpoint, this was a maneuver by FM to keep us from shutting their folks out. From our side, we needed to deal with encroachment and hold up standards just as with peds and IM.

    The key about these deals is not all that many programs get created and there are only a few slots. But by creating these pathways we take away any claim that other specialties can train people to do our job without us. Moreover, it undermines the even more dangerous assumption that FPs and internists can do the job without further training.

    It also undermines the assumption that a pediatrician can practice peds em without additional training. The pediatricians have done the best job with this. To do a peds fellowship following peds residency takes 5 years. Same fellowship following EM, 5 years. To do a peds residency and follow it with EM residency takes 5.5-6 and your double boarded and can do adult as well as peds em. Sound like more fun and better money if you can arrange it.

    I don't know about the reneging thing. I do know that on the CORD listserver, noone was lining up for this, it will require EM PDs to participate, thus having 72 interested FP programs is not enough.

    BTW We recruit for folks already trained in other specialties. I suspect that we've trained more FPs, internists and pediatricians than anybody else. None of my grads are practicing anything but EM. None of the FP/EM types are practicing in the woods. IMneverHO, this is about additional EM slots and the money not rural care.

    When I'm at work, I'll post my comments from the cord server.
     
  26. Apollyon

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    Not according to SAEM, and I went through ACGME, and all Ped EM (Peds) are 3 years.

    I had been told all Peds fellowships were 3 years (with one exception - sports med), but was surprised to find out that, per the program requirements, Peds EM (Peds) WAS only 2 years by statute, but, by 1/2007, all will be 3 years (as per www.acgme.org: "Unless specified otherwise in the program requirements for a specific subspecialty, pediatric subspecialty programs must provide 3 years of training"). So, the program requirements for Ped EM (Peds) is 2 years by rule, but no one follows it - and, interestingly, about half of the programs that have Ped EM (Peds) and (EM) are 2 years for EM and 3 years for peds, which I thought would engender some bad feeling.

    A second point needs clarification: you seem to contradict your own point when you say doing an EM residency, then a peds residency, allows you to do adult and peds EM. I thought that the idea of EM, then peds residency (without fellowship) allowing board certification in peds EM was murdered by the AAP and remains dead and will not be resurrected in the visible future.
     
  27. BKN

    BKN Senior Member
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    My bad, somewhere in the editing I got messed up. What I meant to say was that ped + peds EM fellowship = 6 years, EM + Peds EM fellowship = 5 years, Peds residency + EM residency 5.5-6 years.

    No, I'm not contradicting myself. Do you think a peds hospital would not hire a person double boarded in EM and Peds? That person is better qualified than someone with certification and a special qualifications certificate from one of the two boards. However, you don't see the double boarded guys at the peds hospitals. Usually those guys choose to practice adult and peds em at a general hospital for both money and interest sake..
     
  28. BKN

    BKN Senior Member
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    I said earlier that I would post my comments from the discussion on the CORD listserver. It was a serious discussion with verying viewpoints,but nobody was lining up to participate in this. I would guess there will end up being a few programs and a few slots same as EM/IM and EM/PEDS.

    "I may have some practical experience to offer. I think we've trained more nontrads, including completed specialists than any other program. We have recruited for "mature candidates" since converting to a 1,2,3 from 2,3,4 about 1991. Maturity might be completed residency in another specialty, partial completion of surgical training, practice, military GMO, another professional degree and career (PhD, engineer, social worker, fighter jock, etc).
    Looking back since 1990 we have EM trained 9 FPs and have 3 in training now. We also have trained 4 internists, 2 pediatricians, 5 partially trained surgeons and 10 other nontrads.

    Our conclusions about the FPs? Remember that all had finshed training, some had practiced FP and several had practiced EM up to several years:

    1. They make superior residents, most had very high inservice scores and very high evaluations both by EM faculty and off service. This despite an often lower half performance in med school.

    2. Obviously most are very mature compared to new graduates (including the potential FM/EM trainees being discussed here).

    3. Approximately 50% have been chief residents, compared to <1/4 of the traditionals.

    4. Of the 9 FP graduates, none are practicing FP today, even part time. 2 are academic faculty, 3 are practicing in urban large EDs, 1 is practicing is a large rural ED and I am not sure about the others. This distribution seems no different to me than that of the traditional grads.

    5. Incidentally, residents who have already trained in other specialties don't have to stick. We have had two FPs leave voluntarily within two months. One rang the bell on July 5th! No problem finding replacements.

    So what I think about the questions at hand?

    1. I agree with _____, the new format will do nothing to improve perceived rural maldistribution. This is about more EM slots. The grads will go where the money is and will not practice FP at all.

    2. We need more standard EM slots and will do for at least the next 20 years.

    3. EM training should be a minimum of 4 years long. We need to be PG3s in every other specialty. ACGME and RRC keep adding ever more requirements to an already packed curriculum. Karl Mangold, who hired a lot of EPs, many untrained, in the 70s and 80s used to say that it takes 30K visits to make a good EP and 60K to make an outstanding one. That's 6 and 12 years flat out. Residency training shortens this considerably, but another year would help out. I see a clear difference between the average traditional grad and the average nontrad in our program.

    That's it, the rest is silence.

    Brian"

     
  29. Derek

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  30. SoCuteMD

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    Interesting that BKN, as PD of a 3 year program is advocating for a minimum of 4 years of training for all EPs. Changes in the works in El Paso, BKN?
     
  31. southerndoc

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    I'm really surprised none of the "4 year programs is a $150,000 mistake" advocates aren't taking issue with this.
     
  32. Apollyon

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    At the same time, his program went from a 2-4 to a 1-3 about 15 years ago.
     
  33. FoughtFyr

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    I'm not. I not sure that there are that many folks who don't believe that EM residencies could be longer. I think the concern is that, with the current paradigm, there is no tangible professional benefit (save the chance to be faculty at a four year program immediately after residency) to the extra year. Given that, it takes one hell of an altruistic soul to sign on.

    Let me give you an example. My uncle is an orthopedic surgeon from back in the days when you could be expelled from medical school by a single professor during a class (in fact, his roommate met such a fate). You know, back when medical school started with "look to your left, now look to your right, one of those people won't be graduating with you". He couldn't believe that I could schedule my own Step 1 or Step 2. He told war lies about students with gastroenteritis sitting in diapers because the test was offered once, and only once, a year to all students on the same day. He kept this banter up until he arrived one afternoon to take me out to dinner while I was studying. He took one look at the Kaplan books and said "how the hell are you supposed to know all of this stuff". Later, as he read through them, he realized that our anatomy classes were nowhere close to his (his being FAR more in depth) but he also realized the SCOPE of medicine had grown so much - virology, immunology, microbio, heck, AIDS alone takes up so much. (I'm getting to my point) Not long after that night, I was again out with him and a friend of his from medical school who happened to now be a Dean of a medical college (not mine, and one that shall remain nameless but is considered a "top-tier" school). My uncle and the Dean talked, at length, about the differences between school then and now. The Dean said that he, and more than 3/4 of his faculty, would "love to extend medical education by 2 years - at least" but they felt that doing so would leave them "only with applicants desperate to just be in medical school", as the "top applicants" would look to the traditional 4 year programs.

    Now, I am NOT SAYING, I REPEAT, I AM NOT SAYING that 4 year residents are desperate. Residency is a different kettle of fish. What I am saying, is that many people, myself included, would agree that in an ideal world medical education would be longer and residency training would be longer (in EM). But few are willing to be the first to put their money where their mouth is. I don't know that I would have applied to a six year (after a bachelor's) medical college, if one existed then. I'm not certain that there would have been a tangible benefit worth the extra time. But I do think we'd have better doctors if all medical colleges went to a 6 year program. Likewise, I didn't do a four year residency not because I wasn't sold on the idea that, in a perfect world, EM residencies wouldn't all be four years long, but rather because I wasn't sold that it made that much of a difference (after the first year or two of practice) in the world we live in.

    I now return you to your regularly scheduled thread.

    - H
     
  34. southerndoc

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    There are medical schools now that offer 5-year programs, but most of these seem to be centered on research. Yale and Stanford come to mind for these schools.

    I wonder why the Canadians require 5 years of training to become board-certified in emergency medicine?
     
  35. 8744

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    It's the conversion. Four years American equals five years canadian.
     
  36. 8744

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    Agree most whole-heartedly. The long suffering Mrs. Bear is tired of being poor.
     
  37. Blue Dog

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  38. BKN

    BKN Senior Member
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    Well, I'm gonna resuscitate this a bit since you'all talked a little more after I went out of town.

    SoCute, changes are always in the works at El Paso, but not that one at this time. Whenever I bring it up I get :eek: :scared: . but the windmills are weakening.

    Ap, you're right we did. We needn't go into the ancient history of this, but we had been used to having 3 candidates for every position in the 2,3,4 match and 2 for 1 in the 1,2,3 in the early 90s. There was a pool of people practicing EM who were not trained in it who wanted it and didn't want to be interns again. That pool dried up and suddenly we were 1 for 1 in the 2,3,4 while the 2 for 1 remained in the 1,2,3. Several programs, including TT decided that the wave of the future was 1,2,3 and converted. Naturally since everybody bailed at once the ratios reversed.:oops:

    Also at the time there was a specialty match in December for the 2,3,4 positions that started in the following July. That went away also, I guess.

    Since then Gas got it's extra year, along with Rads and almost everybody else.
    We seem to be stuck in ambivalence (or letting a 1000 flowers bloom) with at least 6 and soon to be 7 formats.

    FF, your story interests me and I can give a little ancient history about going the other way. The last time a large doctor shortage was perceived was in the late 60s. The feds, much more intrusive (or proactive, choose your conservative/liberal label) in those days, offered a carrot. There would be money for each medical student trained and money for new slots.

    In Texas over ten years the number of slots went from about 250 to 1800. Each of the three extant schools doubled their class size and 4 (5?) new schools were founded. Baylor was the most assertive in this. Not only was the class size doubled, but in 72, the basic sciences were cut to one year (11 months instead of the traditional 18). Thus you could do it in 3 years. I was in the first class to be offered it and along with the majority, I did it. It was very difficult to sit in class that first year 40 hours a week and then go home and try to study at all. The people at Southwestern were very critical saying that basic knowledge was increasing not decreasing, so how could the curriculum be cut? But it worked. I have to say that I was a rather immature intern, but I'm not sure that the 3 year curriculum was at fault. I gather Baylor has since expanded Basic to 5 quarters, thus 15 months. I don't know if you can still do it in less than 4 years there.

    So, I certainly understand the desire to get it over with. But as your Dean friend indicated, the amount of info just keeps increasing in both clinical and basic science. The Brits stay in training much longer than us, but as Panda would say, it's the exchange rate. In fact they do spend fewer hours in their work week so it probably comes out about even.

    BTW Panda, I just got back from Canada. The Loonie (Canada Dollar) now = .93 US. So I'm expecting Canadian training to get shorter or ours to get longer.
     

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