FM working in EM?

[DahlkeA]

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So I know I'm just a pre-med student, but one who (at the moment at least) is somewhat interested in ER. Obviously probably will change once medical school comes around, but it's fun to dream.

I just happened to be looking at some of the ER groups websites in my town, and noticed that there tend to be quite a few of Family Medicine doctors working in ER groups... One group I was looking at had about 20% of their staff as boarded FM doctors with no EM. I live in a town that's metro area is only about 600,000 people, so not super small, but not large either. I'm just wondering if this is common or not. How many of the residents or attending out there have FM doctors working with them? Again I'm just a premed, but it seems like the training for EM and FM would be pretty significantly different, but what do I know. I was just curious of this is common place?

 

[DrMom]

I'd recommend doing a search in this forum as the topic has been discussed ad nauseum. Bottom line, if you want to practice emergency medicine, do an emergency medicine residency.

 

[TheJanitor]

Yea, a search will provide you a better answer, but here's what I can say:

Historically EM is a relatively new field. A lot of FM docs got grandfathered in and are still practicing. There are also places that want to staff with exclusively EM docs, but can't - so they hire FM docs. There is a distinct shift away from FM to only EM and, by the time you're out (assuming you go and don't change your mind), you'd be hard pressed to find a job in an ED as an FM MD.

I may be wrong (only an MS-4, new to the field), but that's my understanding

Again, the search function is your friend. Use it in the future, otherwise, people will loose their mind.....

 

[EM_Rebuilder]

Searching will be your friend...

But, those "20% listed" that you saw have likely done this 10+ years. Occasionally those guys get booted, but if they have been a nice guy and put there time in the past, they are likely to stay put.

On the flip side, I would say any town of 500K plus sized in the US will not hire a 'newly minted Family Med physician to staff their Emergency Dept".

As pointed out, we are a new speciality, so we are still playing catch up.

 

[DahlkeA]

Thanks for the responses.

Even after finding this out I would never do FM if I had my heart set on EM. I more was just curious as to WHY there were so many FM guys in an EM practice, but that makes sense. Thanks for clearing that up.

 

[Groove]

Thanks for the responses.

Even after finding this out I would never do FM if I had my heart set on EM. I more was just curious as to WHY there were so many FM guys in an EM practice, but that makes sense. Thanks for clearing that up.

Because there's not enough EM boarded docs to staff all the EDs and you're still going to have a hard time getting the EM boarded guys to staff the 10K annual volume ED out in NowhereVille.

 

[deleted109597]

Searching will be your friend...

But, those "20% listed" that you saw have likely done this 10+ years. Occasionally those guys get booted, but if they have been a nice guy and put there time in the past, they are likely to stay put.

On the flip side, I would say any town of 500K plus sized in the US will not hire a 'newly minted Family Med physician to staff their Emergency Dept".

As pointed out, we are a new speciality, so we are still playing catch up.

It would argue has less to do with the size of the city beyond a certain point, and more to do with the volume of the ED. There are ****box EDs at small hospitals (and "specialty hospitals") that are staffed by PC docs in big cities, but usually once you get past 40K visits a year, it's tough for the PC docs to keep up the pace and stay on the metrics that a hospital that size is forced to meet.

 

[bluewillark]

A lot depends on where you want to practice. I did 2 years of med/peds and then 2 years FP. Started to moonlight after my intern year in some rural ERs. By my last year as a resident I was moonlighting in a 55K volume ER and then had multiple job offers in similar volume ERs on graduating. The majority of docs you will find staffing ERs in my area (oklahoma) are FP docs except at the bigger hospitals in OKC and Tulsa. The good thing about it is you have much more flexibility to do other things when the ER wears you out.

 

[jbar]

Yeah, I figure I'll just work in family medicine when I burn out in the ER, since training in the ER is basically the same thing as family medicine and I should be well prepared for that.

 

[bluewillark]

I never implied FP training is the same. But the simple truth is that in my part of the world you can find all the ER jobs you want as an FP if that's what you want to spend your time doing. There are simply too many hospitals out there and not nearly enough residency trained ER docs to staff every ER in this region. If it was a requirement that hospitals use ER trained docs only, I would wager to bet that over 90% of hospitals in Oklahoma and Arkansas would shut their ER doors. So, realistically, FP offers a good means to do a lot of things in rural America. And when ER trained docs start showing up here willing to work the ER so I can get on with inpatient rounds, ICU, clinic, and my Q 3-4 call nights, I'll be more than willing to share with you.

 

[ptarmigan]

I never implied FP training is the same.

Do you feel well trained and well pepared to staff the ED? (I am asking the question sincerely): What about things like intubations, central lines, chest tubes, arterial lines, crics, codes, lateral canthotomies, thoracotomies, transvenous pacers, fracture and joint reductions, bedside ultrasound for gall bladder/ectopic/aorta/FAST, managing septic shock, upper airway obstruction, the crashing baby, the toddler that needs to be intubated, and multisystems trauma

I have looked at family practice curriculums and they don't contain any of the above. I spent a bunch of years trying to get good at those things and I still feel the butterflies when some cases come in the door. I can't imagine if I had prepared by managing people's chronic hypertension and hypothyroidism in the office. Do you just pick it up as you go? How long does it take?

 

[andwhat]

Do you feel well trained and well pepared to staff the ED? (I am asking the question sincerely): What about things like intubations, central lines, chest tubes, arterial lines, crics, codes, lateral canthotomies, thoracotomies, transvenous pacers, fracture and joint reductions, bedside ultrasound for gall bladder/ectopic/aorta/FAST, managing septic shock, upper airway obstruction, the crashing baby, the toddler that needs to be intubated, and multisystems trauma

I have looked at family practice curriculums and they don't contain any of the above. I spent a bunch of years trying to get good at those things and I still feel the butterflies when some cases come in the door. I can't imagine if I had prepared by managing people's chronic hypertension and hypothyroidism in the office. Do you just pick it up as you go? How long does it take?

Nurses routinely intubate babies in the NICU, toddlers are not difficult typically. Chest tubes are not difficult. The other things are common if you work in a level 1 trauma center. Otherwise, you have Surgery backup if you have any concerns. Difficult intubation by ER trained doctor, even consults Anesthesia if things go awry.

 

[ptarmigan]

Nurses routinely intubate babies in the NICU, toddlers are not difficult typically. Chest tubes are not difficult.

I did not find a chest tube to be easy the first few times I did one, and that was with someone standing there helping me. Maybe I am just a slow learner, but in my experience with junior residents, they need a lot of help and guidance with their first few. Appy's are easy once you have done a few. I'm pretty sure I could do one, but I would not expect someone to trust me to do so.

The other things are common if you work in a level 1 trauma center.

I do not work in a level 1 trauma center and I do the "other things" on a regular basis. Sick medical patients tend to be the people who require the most thought and the most procedures. In fact, all of the trauma pricedure skills are ess important in a level I center where the place is probably crawling with consultants who can help out anyway.

 

[andwhat]

Why do hospitals hire FM and IM, and other specialty boarded doctors in the ER? Should the doctors quit because they shouldn't expect the patients to trust them?

 

[ptarmigan]

Let me say that I know most people on this forum are completely bored of this issue, but it just has never made sense to me.

I am honestly curious how it works. How does the FP become prepared to treat critically ill patients? My understanding of family practice is 33% chronic disease management, 33% preventative care, and 33% urgent care. How many chest tubes, central lines, intubations, fracture reductions, and bedside ultrasounds fo family practice residents do during their training, ESPECIALLY now that EM residents are around? This is not to mention the rare procedures. When do FPs ever learn how to manage acute decompensated shock? The one month in the ICU and 1 month in the ED that the FP residents get where I trained doesn't afford these opportunities. But maybe in other programs they get more experience. I would be surprised if an FP resident at the end of thir residency has done more than 2 central lines and 2 intubations. My guess for average amongst a class would be 0.1-0.5 of each. Maybe they do more and I just never knew it.

So back to my original question - do you pick it up along the way, or do you just avoid these procedures? How do you deal with this?

What about evaluating acute chest and abdominal pain? When do they FP residents get trained to do this? What about eye complaints. Are they comfortable with the slit lamp? I have taught many FP residents how to use one and they seemed pretty clueless, but maybe it was just a weak FP pgrogram.

 

[ptarmigan]

Let me also say I have immense respect for FP and IM docs. I am especially impressed by the ones who can do good job taking care of their own ward patients in the hosptial. I am always asking them questions about things they know more about and I have friends in both specialties. I do not know the first thing about the chronic management for hypertension, hypothyroidism, or hyperlipidemia. I do not know anything about who should get pap smears when, and what to do with CIN grade whatever.

 

[andwhat]

pick it up along the way, do not avoid any procedures. The procedures (for the most part) are not difficult at all, for example slit lamp.
The difference between you or me doing an Appy, is that only the Surgeon has this capability, and hospitals will not allow any other specialty to do one.
Emergency Medicine is vastly different, I have seen several specialties working in the ER, with minimal difference in pay (ABEM vs other specialty boarded)
Med students and solid Pre Meds can evaluate chest and abdominal pain, this is not what separates ABEM vs other specialties such as FM.
Hospitals and administrators realize this, hence the hiring process mainly in community smaller hospitals outside of major centers.
That said, I have immense respect for EM boarded Physicians (ABEM) but above stated differences are not as relevant as critical care. I feel ABEM boarded docs are superior regarding critical care, and like you mentioned central lines and difficult intubations.
However, there is alot of Primary Care in the ER as well. Some people like the variety of patients and procedures. Nights, holidays and weekends are tough, but overall if you prefer working in the ER, and love the work, and you are more passionate, you should actually do an ER residency.

 

[Arcan57]

pick it up along the way, do not avoid any procedures. The procedures (for the most part) are not difficult at all, for example slit lamp.
The difference between you or me doing an Appy, is that only the Surgeon has this capability, and hospitals will not allow any other specialty to do one.
Emergency Medicine is vastly different, I have seen several specialties working in the ER, with minimal difference in pay (ABEM vs other specialty boarded)
Med students and solid Pre Meds can evaluate chest and abdominal pain, this is not what separates ABEM vs other specialties such as FM.
Hospitals and administrators realize this, hence the hiring process mainly in community smaller hospitals outside of major centers.
That said, I have immense respect for EM boarded Physicians (ABEM) but above stated differences are not as relevant as critical care. I feel ABEM boarded docs are superior regarding critical care, and like you mentioned central lines and difficult intubations.
However, there is alot of Primary Care in the ER as well. Some people like the variety of patients and procedures. Nights, holidays and weekends are tough, but overall if you prefer working in the ER, and love the work, and you are more passionate, you should actually do an ER residency.

"Solid Pre-Meds" can evaluate abdominal pain? I'm not on board with that statement at all. Most junior residents (especially non-surgeon, non-EM) do a crap job of evaluating abdominal pain. Hell, I know a cardiologist that does a horrible job of evaluating CP (orders CTA on every patient that is hypertensive, regardless of any other factors). I worked with almost exclusively IM docs at my previous job and they scanned the crap out of belly pain (and taught our NPs to do the same) to the tune of something like 30% of our pts getting cross-sectional imaging.

The truth is that in Arkansas, western TN, southern Missouri, etc. most EDs are staffed by non-EM trained docs (sometimes the director is residency trained, sometimes not). In Memphis, new IM and med-peds grads were hired in high volume EDs because there's not a training program within a 2 hr drive. Trauma got turfed to the surgeons, ob/gyn got turfed to L&D (one of the docs I worked with claimed not to have done a pelvic exam in years, he just ordered a pelvic U/S), and critical care got turfed to the intensivist. If there wasn't an intensivist available to come down, they got a 1L NS or so "bolus" through an 18g IV until they got up to the ICU and got intubated/lined by the intensivist.

 

[andwhat]

"Solid Pre-Meds" can evaluate abdominal pain? I'm not on board with that statement at all. Most junior residents (especially non-surgeon, non-EM) do a crap job of evaluating abdominal pain. Hell, I know a cardiologist that does a horrible job of evaluating CP (orders CTA on every patient that is hypertensive, regardless of any other factors). I worked with almost exclusively IM docs at my previous job and they scanned the crap out of belly pain (and taught our NPs to do the same) to the tune of something like 30% of our pts getting cross-sectional imaging.

The truth is that in Arkansas, western TN, southern Missouri, etc. most EDs are staffed by non-EM trained docs (sometimes the director is residency trained, sometimes not). In Memphis, new IM and med-peds grads were hired in high volume EDs because there's not a training program within a 2 hr drive. Trauma got turfed to the surgeons, ob/gyn got turfed to L&D (one of the docs I worked with claimed not to have done a pelvic exam in years, he just ordered a pelvic U/S), and critical care got turfed to the intensivist. If there wasn't an intensivist available to come down, they got a 1L NS or so "bolus" through an 18g IV until they got up to the ICU and got intubated/lined by the intensivist.

I agree, some people do a horrible job of this in general; scan and call the hospitalist to admit, or scan and call the surgeon to admit. Sometimes do absolutely nothing and call someone to admit. Unfortunately this happens. They are too busy to care.👎
I say they are too lazy to care....

 

[Brigade4Radiant]

So surgeons, IM FM can all work in the ED but EM doctors can't work as a hospitalist or on the wards.It is also harder to get into some fellowships like Critical care and sports medicine when you do an emergency residency.

Seems like EM trained docs get the short end of the stick in job opportunities.

 

[andwhat]

So surgeons, IM FM can all work in the ED but EM doctors can't work as a hospitalist or on the wards.It is also harder to get into some fellowships like Critical care and sports medicine when you do an emergency residency.

Seems like EM trained docs get the short end of the stick in job opportunities.

I have seen Peds working in the ER solo. Haven't seen Psychiatry yet though 😱

The ERs tend to do well with ABEM providers, as well as FM or IM trained providers. From a critical care perspective, obviously ABEM would be the preferable provider in an acute setting with alot of trauma and acuity.

 

[jbar]

So surgeons, IM FM can all work in the ED but EM doctors can't work as a hospitalist or on the wards.It is also harder to get into some fellowships like Critical care and sports medicine when you do an emergency residency.

Seems like EM trained docs get the short end of the stick in job opportunities.

Most EM residents would quit before they agreed to work on the wards or as a hospitalist. It's not really what most of us enjoy doing, so no great loss.

I just see the day coming where places that don't have people who are trained in emergency medicine aren't going to be able to advertise that they have an ER. If you aren't a surgeon or an OB/GYN, the vast majority of hospitals won't let you operate. If you aren't a radiologist, you don't get paid for looking at a film. All it takes is medicare/medicaid saying "we're not going to reimburse for emergency care at the ER rate provided by non-emergency care provers, we're going to pay them for a primary care visit."

Maybe this isn't going to happen. But I think it should. If my family member shows up at an ER, I don't think it's that crazy to expect the person who treats them is trained in emergency medicine. The same way if they walked into a orthopedists office I expect them to be treated by someone who is trained to take care of fractures, not some random internal medicine doctor who decided to just start treating bones because no one else in the area will.

 

[ptarmigan]

Med students and solid Pre Meds can evaluate chest and abdominal pain,

If there is one thing that EM residency has taught me, it is the opposite of what you just stated. Critical care for an EM trained physician is ssssooooo easy. And obviously fast track is brainless. What is hard is the in between - the medium acuity. I remember when I was touring an ED as an MS4 on the interview trail and we got to the medium acuity zone. The faculty member there said, "welcome to the hardest part of emergency medicine."

The NSTEMI that presents as a toothache, VBI that presents as peripheral vertigo, aortic dissection that presents as leg pain and cramping, epidural abscess that presents as back pain after a fall in the bathroom, PE presenting as febrile multifocal PNA, the kid with a URI that ends up having acute leukemic crisis. These are each cases of mine from residency. I cherish those cases more than anything because they have taught me to be humble in approaching medium acuity complaints. All the codes and respiratory failures and trauma blur together, but I remember those cases above like they were yesterday. And I think most malpractice comes out of the medium acuity zones as well. When people are sick, it is easy and obvious.

I would never want an FP coming out of training today to be evaluating chest pain or abdominal pain in the ED. What an unfair position to put them in. They just haven't been trained like an emergency provider. They don't have the framework, the philosophy. The FP residents I have worked with in the ED don't know their ass from their a hole in the ground. And they certainly don't have a reasonable differential for chest pain. I'm sure they are great at managing chronic hypertension, treating rashes and interpreting pap smears. I respect them a lot. But in the words of Peter Rosen, "if I am having a heart attack, get me a cardiologist. If I am having chest pain, I want an emergency physician."

I worked with FP, IM, and surgery trained docs last year while I was moonlighting in a rural ED. It was enlightening. I would come on shift and there would be 10 rooms full, half with potentially life threatening complaints, and they had seen literally 3-5 of them while the rest had been roomed for hours. One had ischemic changes on his EKG but hadn't been seen after 2 hours. I had a 70 year old syncope patient with CAD s/p stent signed out to me as "just send her home when her head CT is done". First, she did not need a CT. Second, I checked a second trop and she ended up having an NSTEMI. I mean it was crazy substandard care. In a trauma, one of the FP docs (actually the best one) put in his FIRST chest tube. The nurses thought I was insane when I put a central line in a paitent with septic shock unresponsive to fluid (Nurse: " I have never seen a doc do that before"). I mean, crazy. Just crazy. I could not believe I was in the US.

My fascination is just how these people can think they are prepared. And I guess they just don't know what they don't know.

 

[Hercules]

I worked with FP, IM, and surgery trained docs last year while I was moonlighting in a rural ED. It was enlightening. I would come on shift and there would be 10 rooms full, half with potentially life threatening complaints, and they had seen literally 3-5 of them while the rest had been roomed for hours. One had ischemic changes on his EKG but hadn't been seen after 2 hours. I had a 70 year old syncope patient with CAD s/p stent signed out to me as "just send her home when her head CT is done". First, she did not need a CT. Second, I checked a second trop and she ended up having an NSTEMI. I mean it was crazy substandard care. In a trauma, one of the FP docs (actually the best one) put in his FIRST chest tube. The nurses thought I was insane when I put a central line in a paitent with septic shock unresponsive to fluid (Nurse: " I have never seen a doc do that before"). I mean, crazy. Just crazy. I could not believe I was in the US.

My fascination is just how these people can think they are prepared. And I guess they just don't know what they don't know.

Your experience I think is a pretty common one unfortunately. I moonlit all across the rural EDs of my state during residency. I have relieved questionably sober physicians as well as retired ophthalmologists who asked their techs to interpret the EKGs. I have been told by nursing staff that central lines are done only in the OR (not today ma'am) and brushed the dust off of ancient chest tube kits that hadn't been touched in years (decades?). It was a little scary but it also helped confirm that I was only interested in going to an all ER residency trained group.

 

[andwhat]

If there is one thing that EM residency has taught me, it is the opposite of what you just stated. Critical care for an EM trained physician is ssssooooo easy. And obviously fast track is brainless. What is hard is the in between - the medium acuity. I remember when I was touring an ED as an MS4 on the interview trail and we got to the medium acuity zone. The faculty member there said, "welcome to the hardest part of emergency medicine."

The NSTEMI that presents as a toothache, VBI that presents as peripheral vertigo, aortic dissection that presents as leg pain and cramping, epidural abscess that presents as back pain after a fall in the bathroom, PE presenting as febrile multifocal PNA, the kid with a URI that ends up having acute leukemic crisis. These are each cases of mine from residency. I cherish those cases more than anything because they have taught me to be humble in approaching medium acuity complaints. All the codes and respiratory failures and trauma blur together, but I remember those cases above like they were yesterday. And I think most malpractice comes out of the medium acuity zones as well. When people are sick, it is easy and obvious.

I would never want an FP coming out of training today to be evaluating chest pain or abdominal pain in the ED. What an unfair position to put them in. They just haven't been trained like an emergency provider. They don't have the framework, the philosophy. The FP residents I have worked with in the ED don't know their ass from their a hole in the ground. And they certainly don't have a reasonable differential for chest pain. I'm sure they are great at managing chronic hypertension, treating rashes and interpreting pap smears. I respect them a lot. But in the words of Peter Rosen, "if I am having a heart attack, get me a cardiologist. If I am having chest pain, I want an emergency physician."

I worked with FP, IM, and surgery trained docs last year while I was moonlighting in a rural ED. It was enlightening. I would come on shift and there would be 10 rooms full, half with potentially life threatening complaints, and they had seen literally 3-5 of them while the rest had been roomed for hours. One had ischemic changes on his EKG but hadn't been seen after 2 hours. I had a 70 year old syncope patient with CAD s/p stent signed out to me as "just send her home when her head CT is done". First, she did not need a CT. Second, I checked a second trop and she ended up having an NSTEMI. I mean it was crazy substandard care. In a trauma, one of the FP docs (actually the best one) put in his FIRST chest tube. The nurses thought I was insane when I put a central line in a paitent with septic shock unresponsive to fluid (Nurse: " I have never seen a doc do that before"). I mean, crazy. Just crazy. I could not believe I was in the US.

My fascination is just how these people can think they are prepared. And I guess they just don't know what they don't know.

you worked with some lazy or overworked docs, wow.....unacceptable, sounds like major dumping to me, has to do more with politics. That is not a representation of the entire spectrum of IM or FM in the ER. That is not an accurate representation of FM residents either (not saying they are perfect) They are likely picking up ER rotation shifts after being on call. Trust me, they are bogged down by office (patients paperwork politics), inpatient, responding to floor calls on patients admitted last night they know nothing about, or even floor codes. If they did ER primarily for say 3-5 months they'd obviously be much more proficient.

 

[Arcan57]

you worked with some lazy or overworked docs, wow.....unacceptable, sounds like major dumping to me, has to do more with politics. That is not a representation of the entire spectrum of IM or FM in the ER. That is not an accurate representation of FM residents either (not saying they are perfect) They are likely picking up ER rotation shifts after being on call. Trust me, they are bogged down by office (patients paperwork politics), inpatient, responding to floor calls on patients admitted last night they know nothing about, or even floor codes. If they did ER primarily for say 3-5 months they'd obviously be much more proficient.

Maybe, but it's hard to overcome training. What you didn't get comfortable doing in residency you're not going to be comfortable doing routinely in practice. And it manifests in not putting in central access when the patient needs it, over-reliance on cross-sectional imaging, and in some cases performing a caricature of emergency care where the only goal is diagnosis, not treatment. We rule out the dangerous, life threatening causes of a patient's symptoms and initiate stabilizing treatment. That's a very different approach then any other specialty's approach to diagnosis, and it shows in fewer catastrophic misses and an ability to handle volume safely that is unrivaled.

 

[bluewillark]

I just see the day coming where places that don't have people who are trained in emergency medicine aren't going to be able to advertise that they have an ER.

Yeah right! Not around here. There are hundreds of small town hospitals across Texas, Oklahoma, Arkansas, Kansas, Nebraska, etc, that have probably never had an ABEM doc in the ER. You really think these places will close their ER doors??? Or should? Why don't you ask the rural residents living in these places what they think about your great plan to make emergency care better by getting the FP docs they know and trust out of the ER's and making them travel 100+ miles for emergency care. Ask the guy who I saw on Tuesday who coded from a STEMI in front of me, but is sitting in the hospital in Tulsa now eating his breakfast with 2 new stents. You think he wants to see you close my hospital and kick me out of the ER?

I'll be the first to acknowledge FP guys don't need to work Level 1 Trauma Centers, that's not our place and not what most of us aspire to. Or even the other high volume ER's. But my part of America depends on FP's everywhere outside of the big cities that have more than 80,000 people.

Do I feel comfortable with the more common ER procedures? You bet. I'm sure our training in FP programs in the south central states is much different than on the coasts.
I did well over 50 chest tubes as a resident. 200+ central lines. 200+ intubations (infants, peds, and adults), multiple other airways. At least 20 IO's on kids. I love to get the slit lamp out. There's not much I can't suture. Did 82 C-sections as primary and have been called on to do it emergently at my hospital even though we no longer provide OB services (would you do one?) I've done a handful of surgical airways - yes they scare me, but I feel capable when it's a must.

Are there more rare procedures I don't do? Absolutely! Would an ABEM doc keep his skills up at doing them out here? Not a chance. Should we put an ABEM doc in every rural ER for the one surgical airway that comes through the doors every 3 years... I would think that's not an efficient use of resources.

It's also worth noting that standard of care varies from region to region and even within a state. It is understood that FP docs in rural ER's aren't the same as ABEM docs in Level 1 trauma centers. I've never heard of anyone in my state advocating to get FP docs out of the ER. Quite the contrary, small towns love their hospitals and are generally extremely grateful to the docs who come there and agree to staff them. So, ER's closing in Oklahoma for lack of specialty-trained ER docs?....not in my lifetime.

 

[andwhat]

Yeah right! Not around here. There are hundreds of small town hospitals across Texas, Oklahoma, Arkansas, Kansas, Nebraska, etc, that have probably never had an ABEM doc in the ER. You really think these places will close their ER doors??? Or should? Why don't you ask the rural residents living in these places what they think about your great plan to make emergency care better by getting the FP docs they know and trust out of the ER's and making them travel 100+ miles for emergency care. Ask the guy who I saw on Tuesday who coded from a STEMI in front of me, but is sitting in the hospital in Tulsa now eating his breakfast with 2 new stents. You think he wants to see you close my hospital and kick me out of the ER?

I'll be the first to acknowledge FP guys don't need to work Level 1 Trauma Centers, that's not our place and not what most of us aspire to. Or even the other high volume ER's. But my part of America depends on FP's everywhere outside of the big cities that have more than 80,000 people.

Do I feel comfortable with the more common ER procedures? You bet. I'm sure our training in FP programs in the south central states is much different than on the coasts.
I did well over 50 chest tubes as a resident. 200+ central lines. 200+ intubations (infants, peds, and adults), multiple other airways. At least 20 IO's on kids. I love to get the slit lamp out. There's not much I can't suture. Did 82 C-sections as primary and have been called on to do it emergently at my hospital even though we no longer provide OB services (would you do one?) I've done a handful of surgical airways - yes they scare me, but I feel capable when it's a must.

Are there more rare procedures I don't do? Absolutely! Would an ABEM doc keep his skills up at doing them out here? Not a chance. Should we put an ABEM doc in every rural ER for the one surgical airway that comes through the doors every 3 years... I would think that's not an efficient use of resources.

It's also worth noting that standard of care varies from region to region and even within a state. It is understood that FP docs in rural ER's aren't the same as ABEM docs in Level 1 trauma centers. I've never heard of anyone in my state advocating to get FP docs out of the ER. Quite the contrary, small towns love their hospitals and are generally extremely grateful to the docs who come there and agree to staff them. So, ER's closing in Oklahoma for lack of specialty-trained ER docs?....not in my lifetime.

extremely reassuring and very helpful. There are several ERs in bigger states on the coast that are the same.

 

[DrMom]

Yeah right! Not around here. There are hundreds of small town hospitals across Texas, Oklahoma, Arkansas, Kansas, Nebraska, etc, that have probably never had an ABEM doc in the ER. You really think these places will close their ER doors??? Or should? Why don't you ask the rural residents living in these places what they think about your great plan to make emergency care better by getting the FP docs they know and trust out of the ER's and making them travel 100+ miles for emergency care. Ask the guy who I saw on Tuesday who coded from a STEMI in front of me, but is sitting in the hospital in Tulsa now eating his breakfast with 2 new stents. You think he wants to see you close my hospital and kick me out of the ER?

I've worked in 2 hospitals that took many transfers from those litte Oklahoma ERs and while we'd sometimes get in appropriately evaluated patients, we often got in patients that were grossly mismanaged in the small, outlying ERs. It was such a big problem that at one of these a policy was instituted requiring transfers for admission had to go through the ER so that anything that should have been done in the outlying ER would be caught and completed and that the patient could be stabilized.

Things are changing gradually in Oklahoma. I work a 2 suburban hospitals and 1 critical access rural hospital. My group is almost entirely EM trained and the few that aren't have worked in EM for a long time and at some of the larger hospitals.

 

[ptarmigan]

I'll be the first to acknowledge FP guys don't need to work Level 1 Trauma Centers,

Why are you so focussed on level 1 vs level 2 trauma centers as a dividing line for what seperates emergency physicians from family physicians? Level 1,2, and 3 trauma do not demand different skill sets. Why are you focussed on trauma at all when talking about what seperates the EP from the FP? Again, trauma and critical care is the easy stuff - its the medium acuity that is hard.

I amazed at the number of procedures you got in residency. 50 chest tubes? 200 lines? 200 intubations? That is truly remarkable and probably more than the typical EM resident gets.

As you know, procedures aren't everything. But even then, I think FP residents access to procedures such as you had is rapidly dissapearing. I would doubt that the FP residents coming out of training today are doing more than 1 or 2 chest tubes, intubations, and central lines.

 

[ptarmigan]

A few people have made good points about the shortage of EPs. As we get more EM trained grads out there, how is our specialty going to deal with the fact that there aren't any EPs that want to live in rural Texas, Oklahoma, Arkansas, Kansas, or Nebraska? Those new grads are going to want to be working in bogger cities on the coasts and in the mountains just like we want to. More grads is going to make the competitive areas more competitive while the gaps don't fill in.

So maybe we should as a specialty be teaching in Texas, Oklahoma, Arkansas, Kansas, and Nebraska how to practice EM, ATLS style. Maybe EM fellowships are a good idea in these areas.

Also, how as a specialty are we going to deal with the EDs with a census less than 10,000? Contracts at those hospitals aren't profitable compared to our EDs where we can torque the staffing grid for every RVU it is worth. The billings at critical access hospitals just don't support an EPs slaray. None of us want to work for a buck an hour and EPs are not clammoring to drive 3 hours into BFE so we can be paid to sleep. It seems like this problem is going to be with us for a long time.

 

[Old_Mil]

I'm an EM grad and work with one grandfathered GP and FM trained folks. There is a difference in the thought process. This having been said, there's nothing preventing someone who goes to a low OB track FM residency, does a lot of ER electives, and does an ER fellowship from becoming a competent ER physician.

This really is a misguided debate with the incursions that PAs and NPs are making into the practice of Emergency Medicine. There are rural ERs that are strictly staffed by midlevels with no physician on the premises. If you allow this sort of thing to continue we will soon find ourselves in the same situation as anesthsiologists.

Rather than tilting at windmills while ignoring elephants in the room, our colleges (AAEM/ACEP) need to work together with family medicine come up with a legitimate, rational training track.

 

[ptarmigan]

I have worked with grandfathered GPs as well and they are some of the best. Partly that's because they have been practiing EM for 30 years - many of them didn't write lisinopril scripts and see rashes for years before they started working in the ED. I think there is a big difference between someone who grandfathered in 20 years ago and an FP resident just coming out of training. Residents used to have a lot more responsibility, a lot less supervision, and the procedures in the ED were there for the taking. Now there is a ton more supervision, many more layers of trainees, less procedures overall (remember when everyone who was marginally sick got intubated? - now we are so comfortable with emergent airways that we can let things wait a bit in the hopes of saving someone from the complications of the vent, not to mention BiPap) and EM residents in the EDs are now snatching up the procedures. There is way less room for the FP resident in a lto of EDs these days. We had FP residents rotate through my program and I gaurantee you they were not at the head of the bed.

Really good point about not ignoring the PA/NP problem. Unfortunately, I have worked with PAs that I would way rather have single coverage over certain FPs in the ED, but also vice versa. On balance, I think it is better to have a dotor there. But I think you are right - they need to be competent and have recieved some sort of EM training - not just "on the job training". But how do we get them the training they need to practice in these rural EDs without them threatening our own specialty in the 10,000+ centers? If they are trained to do EM, can't they threaten to undercut our groups for a lower price?

 

[deleted109597]

Do I feel comfortable with the more common ER procedures? You bet. I'm sure our training in FP programs in the south central states is much different than on the coasts.
I did well over 50 chest tubes as a resident. 200+ central lines. 200+ intubations (infants, peds, and adults), multiple other airways. At least 20 IO's on kids. I love to get the slit lamp out. There's not much I can't suture. Did 82 C-sections as primary and have been called on to do it emergently at my hospital even though we no longer provide OB services (would you do one?) I've done a handful of surgical airways - yes they scare me, but I feel capable when it's a must.

I'm going to be the first person here to say that you're lying. There is no way your program gives you more than the requirement of procedures for EM, and done a "handful" of surgical airways (most programs only get them in cadaver/pig/sim lab), at the same time got 82 cesareans (or, more than some OB programs, although not above the 10th percentile cutoff for "standard"). So either you did a year of anesthesia, a year of OB, and a year of CCM, or you never went to FM clinic.
So which is it, are you a terrible EM doc, or a terrible FM doc? Because you can't be excellent at both.
You are the reason EM can't get a fair shake as a specialty. You continue to argue that the training doesn't matter because you obviously learned it all on your own.
Yes, there are not and never will be enough doctors to staff every emergency department in the land. There also aren't enough ortho, rads, cardiology, oncology, GI, derm, etc. Hell, there aren't even enough FM doctors, and some are staffed by midlevels.
But for some reason, the rural doc, who valiantly tries to do radiology, cardiology, oncology, GI, and emergency medicine with the training he has, doesn't try to call himself a radiologist, cardiologist, oncologist, or GI doc, but does call himself an ER physician, as if their specialty isn't important enough.

 

[Old_Mil]

Really good point about not ignoring the PA/NP problem. Unfortunately, I have worked with PAs that I would way rather have single coverage over certain FPs in the ED, but also vice versa. On balance, I think it is better to have a dotor there. But I think you are right - they need to be competent and have recieved some sort of EM training - not just "on the job training". But how do we get them the training they need to practice in these rural EDs without them threatening our own specialty in the 10,000+ centers? If they are trained to do EM, can't they threaten to undercut our groups for a lower price?

What I would like to see is for AAEM/ACEP to make an arrangement with the AAFP so that graduates of low OB track FM programs who had completed a specific emergency medicine track in residency AND a one year Emergency Medicine fellowship would be given a formal blessing to work in lower volume ERs. Establish some sort of a cutoff (Trauma I,II,III hospitals are reserved for ABEM guys, for instance).

As far as undercutting our groups for a lower price, I'd much rather see all physicians speaking with one voice because the greater threat comes from midlevels. It's only a matter of time before hospital CEOs make a strictly financial decision: Can I pay this PA or NP 80k or 90k a year to operate independently in my ER, and is the acuity of what we see here low enough to that the potential malpractice losses are less than what I'm saving in staffing costs? If so, why should I pay a trained AAEM/ACEP/AAFP physician two or three times as much? In a sense they are already making this decision by staffing fast tracks with midlevels. It isn't much of a stretch for them to extended that logic to independent practice. We must defend the idea that ONLY a physician is qualified to provide independent medical care to patients. Lose this, and the whole profession will get flushed down the toilet in a shortsighted effort to protect paychecks for one generation of physicians.

Ask yourself - especially if you're working in a trauma center - how many of your nurses have it in the back of their minds to go to CRNA or NP school?

 

[bluewillark]

I'm going to be the first person here to say that you're lying. There is no way your program gives you more than the requirement of procedures for EM, and done a "handful" of surgical airways (most programs only get them in cadaver/pig/sim lab), at the same time got 82 cesareans (or, more than some OB programs, although not above the 10th percentile cutoff for "standard"). So either you did a year of anesthesia, a year of OB, and a year of CCM, or you never went to FM clinic.
So which is it, are you a terrible EM doc, or a terrible FM doc? Because you can't be excellent at both.
You are the reason EM can't get a fair shake as a specialty. You continue to argue that the training doesn't matter because you obviously learned it all on your own.
Yes, there are not and never will be enough doctors to staff every emergency department in the land. There also aren't enough ortho, rads, cardiology, oncology, GI, derm, etc. Hell, there aren't even enough FM doctors, and some are staffed by midlevels.
But for some reason, the rural doc, who valiantly tries to do radiology, cardiology, oncology, GI, and emergency medicine with the training he has, doesn't try to call himself a radiologist, cardiologist, oncologist, or GI doc, but does call himself an ER physician, as if their specialty isn't important enough.

Don't drive angry! OK, to be fair, I didn't do 3 years of FM straight. I started in Med/Peds at a major university hospital where I trained for 2 years. On IM we staffed a 40 bed MICU and residents got to do all intubations (unless they got difficult and anesthesia would come). I was intern in the last days of Q 3 call (they were just thinking about starting with these new work rules). Did central lines nearly daily on my ICU months and several times a month on the wards. I also had a particular interest in doing them and was known for being good with them, so often got asked to teach when other residents not so comfortable. My peds months were in a major free-standing children's hospital, so the same with infant and peds intubations on NICU and PICU months. It was the only peds ER in state, so also saw a lot during ER months and on call in ER.

After 2 years, I was licensed and my Guard unit called me up and sent me to Iraq for a year. That was basically like a year of ER residency and where I got good at chest tubes and where I did first surgical airways (I hadn't ever seen one until then except in cadaver lab at ATLS).

After Iraq, came home and decided to finish in an FP program. It was located in a 400 bed community hospital that served as the referral center for a population of about 500,000. Unopposed program, so no competition with any other residents and most all the specialists at the hospital loved to teach and get residents involved. We did longitudinal OB in addition to our dedicated months. A resident had to be in attendance at every C-section and most were able to assume as primary after their first year. Lots of Medicaid and uninsured which lessened the threshold for the attendings to let us do them (right or wrong).

Our ER experience was also longitudinal in addition to required ER months. Our ER at the community hospital was staffed 24/7 with either a 2nd or 3rd year FM resident in addition to the attending ER doc (most of whom were FP or IM trained, I think 2 were ABEM). The volume was usually around 50 to 55K/year with great mix of pathology and quite a lot of trauma. As an upper level resident you would take ER "call" coverage (not call at all - it was an ER shift where we saw every other patient presenting, handled all their care and discharge or had to write the admit orders when needed before passing them off to the other upper level resident who was on-call for the house). That call was Q4-5 alternating with the in-house calls. In-house call meant responding to every code and crashing patient and nurse call. Residents did vast majority of all lines and intubations. We were primary call for all ICU issues and wrote all transfer orders and vent orders when someone went to the unit (only had one critical care doc for the entire town). Each resident also was responsible for covering his own panel of patients (roughly 1500) longitudinally when they were hospitalized. That meant making rounds twice a day regardless of what rotation you were on and you were expected to do what procedures they needed in the course of the day. All patients admitted to the hospital were followed by a resident as primary. The private attendings (FM and specialists) loved it because all the notes would be done.

Oh yeah, I also did two months of anesthesia elective which was basically just going to the OR and starting various lines and blocks and intubating people. Would usually tube 5-8 people on a given day that elective. We didn't stay for the entire case, just long enough to get the procedures. It's not hard to rack up intubations that way.

Maybe I'm naive about this. I realize I was essentially a 5 year resident and not standard-mint FP, but I would have thought my experience with my FP program was somewhat similar to what FP people were getting in other places - at least in unopposed community programs???

I am happy to say we can agree that some stance needs to be taken with mid-levels. We have some hospitals in this region that have gone to staffing the ER with mid-levels 24/7, some who don't even have anything more than a month or two of dedicated ER rotation.

 

[Druggernaut]

The majority of docs you will find staffing ERs in my area (oklahoma) are FP docs except at the bigger hospitals in OKC and Tulsa. The good thing about it is you have much more flexibility to do other things when the ER wears you out.

I'll leave the discussion of how well-qualified family practitioners are to be working in the ED to those who are in the trenches every day, but I just wanted to draw some attention to this. How do you think you'll stay current with FP if you're working in the ED for 10 or 15 years after residency? When someone says that he'll simply transition back to the clinic after he gets burned out on EM, it strikes me as either over-confident or dismissive of FP. Would you trust a CT surgeon to do a CABG on your mother, or a critical care physician to look after her in the ICU afterwards if they'd been away from their field for a decade or more? I certainly wouldn't.

So either the people who say this is a reasonable course of action think that they're just that good, or that family practice isn't a big enough deal that you need to keep up with current guidelines and therapy. To me, it seems like they'll just be a sub-par emergency physician, and then a terrible family practitioner.

 

[ptarmigan]

Maybe I'm naive about this.

I believe you are being naive to think that your procedural training over five years of residency with combat military field experience thrown in would be anywhere close to an FP residents training. Take a look, you will be suprised. Ask some new FP grads how many months they have spent in the ED and how many central lines, intubations, chest tubes, and fracture reductions they have done. I bet you will be surprised. And that is the easy part.

FP residents train to see patients in the office. Again, a third preventative care, a third chronic disease management, andf a third urgent care (rashes, colds, etc). Absolutely zero of this is what an EP needs to know.

Great point above - this fantasy of sliding back into family practice after doing EM for a lifetime. The arrogance that you still would know how to do preventative care and chronic disease management after a lifetime of not doing it. The willingness that you have to provide your patients with substandard care. FP is a freaking SPECIALTY. It requires SPECIALIZED knowlege. Why do you want to not practice your own specialty, then do someone elses, then retire back into your own 20 years later. I guess it is the same arrogance that makes you think you can do our job without any training. Also, you must have never actually done FP if you think it is something easy that you can start when you're 60. Good luck with that . . . building up a patient base and seeing 4 per hour at age 60 . . . you obviously have no idea what being an FP entails.

Just curious . . . How does someone who has done zero or one or two central lines, intubations, chest tubes, or fracture reductions get credentialled to do them?? The reason I can't do appys (even though they are easy) is because the hospital actually has standards for surgeons. Evidently they do not have standards for the providers who work in their EDs.

 

[Apollyon]

a third urgent care (rashes, colds, etc). Absolutely zero of this is what an EP needs to know.

Actually, this last third is ABSOLUTELY what an EP needs, considering what we see.

Alternately, I have said that not a medic with a protocol book, not even a monkey, but a machine could do 95% of our job; we are there for the 5% that need immediate, high-level intervention that can't be predicted when it will occur and where the fine details do matter. However, for the times when the critically ill and injured aren't there, we need to know the nuances of the lower-level stuff.

A police officer isn't making A level felony arrests all the time; that is quite a rarity. He is on the job, though, and doing the daily, little stuff. The "broken windows" theory of police parallels our job rather well.

 

[ptarmigan]

It's a good point, we do still see urgent care and that does overlap.

I respectfully disagree with your statement about machines doing our jobs and the critical care being the hard stuff. I personally feel that critical care is the easy part of my job. Its the medium acuity patients with normal VS that I find to be quite challengin (finding that sentinel bleed, VBI in a 50 year old, , PE presenting as PNA, NSTEMI presenting as dental pain, telling that 40 year old chest pain with 1 risk factor and a mediocre CP story they can go home and follow up with their PCP for a ETT, etc). That is the part I am most worried an FP never gets (even if they do get the procedures).

 

[ptarmigan]

Also, true urgent care is probably only 15-25% of what I do. I don't ghet many gimmies because it is all skimmed off by our fast track. When I get a straightforward UTI or a med clearance it always makes me happy. A good 60-75% of my practice is medium acuity that requires varying amounts of thought, and maybe 10-15% critical care.

 

[bluewillark]

FP residents train to see patients in the office. Again, a third preventative care, a third chronic disease management, andf a third urgent care (rashes, colds, etc). Absolutely zero of this is what an EP needs to know.

Great point above - this fantasy of sliding back into family practice after doing EM for a lifetime. The arrogance that you still would know how to do preventative care and chronic disease management after a lifetime of not doing it. The willingness that you have to provide your patients with substandard care. FP is a freaking SPECIALTY. It requires SPECIALIZED knowlege. Why do you want to not practice your own specialty, then do someone elses, then retire back into your own 20 years later. I guess it is the same arrogance that makes you think you can do our job without any training. Also, you must have never actually done FP if you think it is something easy that you can start when you're 60. Good luck with that . .

I have a routine family practice that mirrors what most FP's in rural Oklahoma do. I cover my own inpatients, cover the ER on a rotating basis with the other FP's in town (because we don't have ABEM docs anywhere around here - a point you guys just want to keep skimming over), and work in clinic from 8am to 5pm (if lucky) seeing 30-40 patients a day. The other FP's in town are significantly older than me and trained in the days prior to EM programs and have been doing rural medicine their whole lives. We haven't been able to recruit a new FP in the past 3 years even though most of us here make > 300K/year. I guess the difficult part is that there's nothing much to spend it on out here, but it makes for a good family life as the wife and kids and I get to spend most all of my non-work time together. Maybe I only speak for what is becomming a dying breed of generalists who are capable of performing in many different settings. I don't claim to be a radiologist, but I read all of my own films. I don't claim to be a surgeon, but I do lots of minor surgeries and endoscopies. I don't claim to be a psychiatrist, but I have to manage psych meds all the time and be a capable counselor. I don't claim to be an endocrinologist, but I manage all of my patient's insulin needs. I don't claim to be an ER specialist, but there aren't any here and the people of this county keep coming through the ER doors. Family Medicine is a specialty, but only in the sense that we have to be proficient in the common diagnostic strategies and treatment modalities of ALL specialties, to include the ER.

 

[ptarmigan]

Your practice sounds pretty badass. It also sounds really demanding. I'm glad we have dedicated physicians like you in rural America. As you said, there aren't any EPs there, so the argument about who is better is moot. Hard to criticize someone who is out there doing what others don't want to do.

Rural and non-rural FP should be different specialties in my opinion. What you are doing bears no resemblance to what FPs do in my area, and your training bears no resemblence to the training FP residents I knew recieved.

According to the USDA, 16% of the US population lives in rural (or nonmetro) areas, defined as towns with a population less than 50,000 people. But that 16% of population covers 75% of the land area. Incredible. It seems like rural america is everywhere (which it is), but it is such the minority of America by the numbers.

So the majority of FPs are practicing in urban areas where they are going to be seeing people in the office only, using hospitalsts for acute hospitalizations, and dedicated emergency providers for the evaluation of acute complaints. These FPs are nothing like you, and they are not prepared to staff an ED.

 

[EdibleEgg]

I'm in a similar situation. I finished an aggressive FM residency and did a rural medicine fellowship afterward. My numbers weren't quite as good as bluewillark's, but they were close. I never planned on doing any EM moonlighting, but it's hard just to get warm bodies here. I can guarantee you I do more for the health of the patient's in this community during my shifts in the ED than the vast majority of the locums (EM boarded or not) that come trough here. The 1/3 preventative, 1/3 chronic disease, 1/3 urgent care was not true of my training. I would quit medicine and farm full time if I had to do routine physicals or write lisinopril all day.

I generally don't care much about this argument. It's really meaningless until there are so many EP's the market is flooded, and some of you are forced to move to the country to keep a job. The only reason I have a dog in the fight at all is it has been so difficult to find another partner. It's not that people are not willing to come, they just don't get the training to practice in this environment. The rule of thirds become a self-fulfilling prophecy. I saw it happen to some of the residents in my program, and I think it is getting worse.

By the way, we are not the enemy. The administration here has, in the guise of getting wait times down added a mid level on a 10-10 shift in the main ED. One of the PA's hired to do this is a good friend. He was told by the administrator who hired him, "Learn everything you can." because they are planning to place the mid-shift physician with a PA after six months of experience.

 

[deleted109597]

By the way, we are not the enemy. The administration here has, in the guise of getting wait times down added a mid level on a 10-10 shift in the main ED. One of the PA's hired to do this is a good friend. He was told by the administrator who hired him, "Learn everything you can." because they are planning to place the mid-shift physician with a PA after six months of experience.

Yes you are. You're still the enemy. You're still diluting our specialty when you say you practice emergency medicine.

Look, I have no problem with FM docs doing rural medicine. Rural medicine sometimes includes first responder type activities, but isn't the same as emergency medicine. Many, if not all of us, have worked in rural EDs when we moonlight. The standards are so laughably not the same that sometimes I fear for those people. However, the rural docs are able to do so simply because they have the benefit of followup. Sure, you want to send someone home and see them in clinic in a day or two? I don't think that's wrong. It's just not rational for EM docs to provide patients with that kind of followup.

As before, rural medicine is always going to be different, and I applaud those that want to do it. And you're right, even after we saturate the market (unlikely), there will still be a paucity of docs who want to practice in rural locations. But calling what you do emergency medicine isn't going to fix the problem, no matter how much you want to say it is.

 

[EdibleEgg]

Fine. I'm scheduled for three shifts this weekend. You can come work them and we can be friends.

If you can't make it, what should I call what I do?

 

[deleted109597]

Fine. I'm scheduled for three shifts this weekend. You can come work them and we can be friends.

I never said we weren't friends.

If you can't make it, what should I call what I do?

Rural medicine. Since that's what it is.
Of note, I couldn't work it this weekend because I'll be at ACEP Scientific Assembly. What, you aren't going? I thought you considered yourself an EP?


Again, I don't think calling it rural medicine is disrespecting what you do. However, I think you calling it emergency medicine is disrespecting what we do. And the more EP specific training, the more likely an FM doc is to not work in rural areas, and instead go to larger cities (that require such things).
There aren't enough EPs to staff the world, and what you all do is laudable. But just like putting an EP on every ambulance is an impossibility, we shouldn't call paramedics EPs either.

 

[ptarmigan]

what should I call what I do?

What if you called it family medicine, and yourself a family doctor?

 

[EdibleEgg]

Of note, I couldn't work it this weekend because I'll be at ACEP Scientific Assembly. What, you aren't going? I thought you considered yourself an EP?.

What if you called it family medicine, and yourself a family doctor?

You are missing my point and just taking a chance to be a smart ass. I've never claimed to be boarded in Emergency Medicine, I've never asked for grandfathered into any certification. I never even planned to work in the ED.

I really don't care what you call me. But you are being simple minded to call me the enemy and speak of what a problem it is that others like me work in the ED without offering any solutions. If things go the way you seem to want them, there will be a couple of EM residency trained guys here supervising a bunch of PA's. I don't see how that helps you, but I do see how that harms my friends and family when they need emergency care.

 

[ptarmigan]

Edible -

I wasn't meaning to be a smart ass. I'm actually serious. Why did the family docs that I worked with in rural EDs have white coats that said emergency medicine? It's family medicine and you should be damn proud of it because it is a great specialty - especially when you practice in rural areas and get to do everything.

In my limited experience, the PAs in my practice who I supervise provide much better care than the FPs I have worked with in rural EDs. I don't like that fact, but it has been true for me. Now, I might be comparing elite PAs to bad family docs, so maybe on balance it does come out in the FPs favor. I want all EDs to be staffed by MDs, but I feel conflicted by my experience. I have only worked in 3 rural EDs, so maybe I just didn't get a good sampling. If you are getting 200 intubations, 200 central lines, and 50 chest tubes in residency, that is incredible and you are in a different category than the FPs I have worked with.

I don't know what the solution is. I'm just colored by my experience. CT head and c spine for ay syncope but sending an 70 year old syncope with CAD home after a single set of enzymes. CT for any abdominal pain, but not doing pelvic exams on female repro age lower abdominal pain. Not working up chest pain "because he comes in for it so often." Sending 1 month olds with fevers home without a septic workup, but putting IVs in and sending CBCs/7s on kids with URIs. Letting patients wait 2 hours in treatment rooms in a 10 bed ED, letting the nurse enter the orders, and then turning them over to the next doc. It was really an eye opening experience for me.

On the other hand, as I posted above - it's hard to criticize the docs who work where no one else wants to. EDs with a census <10,000 can't really support an EPs salary, and EPs don't want to commute 3 hours to work in a slow ED anyway.

Maybe my experience with FP docs practicing in EDs is unlike where you are, and I am glad of that.