FM working in ERs?

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Just curious, but does an FM residency train adequately to work in the ER?

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Just curious, but does an FM residency train adequately to work in the ER?
For the majority of FM residencies, probably not.

Perfectly adequate for hospitalist work if that's your jam.

Roughly 80% of what presents to an ER should be within the scope of an FM doc but the other 20% can be a different story entirely. Are you adept at managing trauma, difficult airways, refractory dysrhythmias, findings subtle signs of cardiac ischaemia, etc? A lot of this stuff isn't frequently taught or managed during an FM residency.

Sure, you'll find some places that will hire you even with marginal EM experience but it's your patient's lives and your license
 
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Family medicine residency on its own probably doesn’t have enough emergency medicine exposure to allow you to practice comfortably in the emergency department (ED). If you’re going to practice independently and/or as a senior clinician in the ED, I would recommend either: a) formally completing emergency medicine residency training and becoming board certified, or b) as a family physician, spend at least 12 months working in ED plus 6 months in intensive care and 6 months in anaesthesiology to gain experience managing critically unwell patients (including children), run resuscitations, manage trauma, develop good airway skills and know how to anaesthetise/sedate someone for procedures, use a ventilator, in addition to learning how to work the floor of the ED including coordinating patient flow, disaster management, supervising and advising junior staff, and liaising with inpatient teams and pre-hospital ambulance services. I make sure to also keep my ALS, APLS, ATLS, POCUS certifications and skills up-to-date if I’m working in ED. That’s my perspective as a family physician who has worked in both rural/regional and metro/city EDs.
 
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I can’t speak for if it trains you adequately because I’m an M3, but all of the rural EDs I’ve been in on my clerkships are covered by FM docs. They take ED call on top of their outpatient clinic, so they’re not full time in the ED.
 
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No, it doesn't. You don't get enough experience to manage emergency cases

I know several doctors who do EM coming from different specialties. In my experience, surgeons tend to be the best outside of emergency medicine trained physicians. IM doctors are bad because they don't even have enough ob/gyn or pediatric experience, but adults they tend to adequately. FM doctors tend to over admit, and the lack of ICU training shows there's a gap in complex cases. Those who do the fellowship are better but not comparable to EM trained

If you want to do EM, go into EM. It's easy now
 
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The Australians realised that most ERs and hospitals in rural and regional are were predominantly staffed by Family Physicians. Insofar that in Australia, there is a subspecialty track within FM to become a 'Rural Generalist' where FM physicians are upskilled with better emergency and hospitalist skills. I'm not sure if they have this in America or other countries, but as a rural FM who went through this rural fellowship program I feel better equipped to handle most stuff that comes in through ER.
 
This is coming from a rural family medicine resident, but my answer is 'maybe'.

In family medicine you aren't trained to be an ER doc, you're trained to be a good clinician and hospitalist (some programs). so unless you want to get well rounded education that will more adequately prepare you for emergency medicine, you will be trained to be a good generalist. Family medicine residencies don't emphasize certain core parts of emergency medicine such as procedures, treating acute severe medical problems, and pattern recognition on medical problems you don't typically see since FM residents aren't in an acute ER that long in residency.

Now, with that being said you can overcome alot of your deficits but that begins day 1 in residency, and with a recognition that your learning will need to continue above and beyond your EM trained peers once in the workforce.

As an example of how to partially overcome the knowledge deficit, My program is unapposed in 450 bed hospital, so i'm constantly intubating, putting in central lines, rescusitating patients, and handling complex acute patients since there's no other residency program here to take that from me. I'm also aggressive at filling in my knowledge gaps when it comes to procedures (did two chest tubes this week alone) since you can pass on this stuff in FM and noone will fault you for it. Electives need to be more focused, We have 2 months of ICU in our 3 years, so I added an extra month this year. And of course nothing will replace being in the ER, our program has 3 months of ER time (compared to an average of 18+ months for EM residencies) so that needs to be compensated partially with extra months in the ER (I'll have 6 months of ER time). On the side I am also purposefully doing urgent care moonlighting and small rural ER moonlighting where acuity is typically less to get practice in.

I'm doing this since I want to be versatile and know that rural ERs have a real need for well rounded trained physicians. I know I've got my clinic and inpatient stuff down since there is such an emphasis in FM residency already. doing this ER emphasis will help me for being more versatile in the ER.

Just my perspective.
 
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Look into emergency medicine fellowships. They’re not ACGME, but would probably make you more competitive for job placement outside of academic positions.
 
Look into emergency medicine fellowships. They’re not ACGME, but would probably make you more competitive for job placement outside of academic positions.

These can be really good options for those who want that solid dose of experience with skilled guidance prior to entering the workforce. I like to think of these fellowships as "first year of being an attending, without the liability of killing people with your knowledge deficit".

I have talked to some ER medical directors and FM ER physicians and this IS NOT required to get jobs in Rural ERs if that is the only reason that people think they need to do the fellowship. ER's need to make money and have providers on staff in order to see patient's. the higher the risk of not being adequately staffed the more lax they will be on the requirements to work there.

In my area having '1 year practicing in ER experience' is a typical requirement to work there, and some ERs don't even have that requirement. A few places in my area just don't want FM docs since they have enough applicants they don't need to dip into that pool. as an example my area, with one major ER and 6 smaller ERs, only the major ER and one of the smaller ERs they own don't want FM trained physicians. the others are ok with NO experience listed or at least 1 year (I think one wants 2 years).

I say this because you SHOULD NOT use the ER's williness to sign a contract with you as a sign you are competent to do the actual job. Make sure you are ready, and if there is any doubt or realization that you have knowledge deficits you should fix it with a fellowship or working in ER's/hospitals with supervision to gain the skills prior to the real deal.
 
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Be wary of generic replies like "FM does not train you for ER work". There is no "one" FM and one's own experience should not be used to speak for the entire field.

That said, yes it's mostly true but there's a wide range among the 500+ programs and I believe there are at least 10-20 that do provide solid training, and in some areas, perhaps more so than some of exposures that ER residents get (OB, Peds emergencies) and even procedurally (my own experience with intubations and advanced airway management among others).

See this thread and logs here:
 
No, it doesn't. You don't get enough experience to manage emergency cases

I know several doctors who do EM coming from different specialties. In my experience, surgeons tend to be the best outside of emergency medicine trained physicians. IM doctors are bad because they don't even have enough ob/gyn or pediatric experience, but adults they tend to adequately. FM doctors tend to over admit, and the lack of ICU training shows there's a gap in complex cases. Those who do the fellowship are better but not comparable to EM trained

If you want to do EM, go into EM. It's easy now
In order to save EM from the crazy expansion that is going on right now, it should become a 2-yr fellowship (instead of a residency) for some specialties (FM/IM/ Peds etc...).
 
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I am a board certified FM doc who has never worked a day in FM since residency. I have over a decade of experience of EM and can say it depends on a lot of factors: Your drive, your educational aptitude, your environment, your tolerance for risk, etc.

My hospital in residency only had two programs, FM and EM. We pretty much ran the whole hospital, from OB/GYN to shock trauma. I spent all my elective rotations in the ER, moonlight in the ERs as soon as I could and, if I am honest, I would even say my performance in residency suffered as a result the additional educational load. Keep in mind, this will probably not win you resident of the year within your FM program.

Even with all of this, I still was not totally prepared. There was a steep learning curve. There does come a point to where, through experience and education, the gap between you and your BCEM collegues will close (clinically speaking, politically is another story). At this point of my career I would put up my EM skills against any of my BCEM buddies. But you will start off behind. Possibly way behind. If you are too far behind, you will not have a job for long.

The irony is that the majority of places you will be able to work at are the places that have little ancillary support, few specialists, and are the places that really need the best EM docs they can get. Working in major city hospital (the ones you probably cant work at) with 3 docs 5 midlevels and every specialty from ortho to rhumetology is hectic, but not THAT difficult. You got a question or need a hand? Ask someone. activate the trauma team/stroke team/cardiac team. When your the only doc in the whole hospital at 3am and 5 year old comes in unresponsive from rolling an ATV (cuz weather sucks and halo cant fly) and needs intubation and a chest tube, maybe a pericardiocentesis and all you have is your nurses and maybe a respiratory tech.....you better know your stuff.

That being said, the EM outlook is pretty bad right now (see match results) With in the next 5-10 years there will be gross oversupply of BCEM docs that will have no choice but to work at those locations due to saturation and they will always be more more valuable than you. EM itself it now corporate driven (95%) and cut throat. The companies that hire you will drop you in heartbeat. There is no loyalty, you will have no say in your work enviroment and job security is non existent. You may find yourself without a job even if you are good at it. The good news is that as FM, you will always have options. That is big plus.
 
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Just curious, but does an FM residency train adequately to work in the ER?
“Adequate”. Definition is subjective.

You can work in ER as a FM but you’ll need some procedural skills and some EM specific knowledge.

Unfortunately even EM residencies don’t prepare you for many things you see in ER.

There are ways to minimize unknowingly harming patients as an FM working in ER. Learning. Double checking to see if your actions are correct.

Example. I had a patient whom I called code stroke for who had vertebral artery dissection. I wasn’t sure if the BP management is like that of an aortic dissection. An EM residency trained doctor said to keep BP low like in aortic dissection. I wasn’t sure if that was correct. I spoke w neurologist who said to treat it like a stroke (posterior stroke). Permissive HTN is recommended upto SBP 220 in ED.

There are many instances where EM trained doctors decide to do things that are not correct where FM doctors with more live EM experience know better.

It’s the first few years of working in ED after FM training that are the most daunting that are relatively much easier for EM trained doctors.

This is where EM fellowship or any form of other experienced good EM doctors supervising you is necessary for Fm trained doctors to be able to work in EDs.

ABPS BCEM is the only pathway available to us, FM trained doctors who are EM doctors. It is the only thing we have. We must be smart to have that under our belt because when patients don’t do well and people question you for not having done EM residency, you better believe that’s going to be helpful to you. It is a great way to remind yourself the important basics and details of common true EM cases; preparing for written then oral ABPS BCEM board exams. Also, the process of choosing and submitting EM cases to the ABPS in order to get the BCEM is educational. By doing these (studying and taking the written and oral boards and turning in cases), you get reminded of the basic concepts and details of common EM cases. I found the tests to be refreshingly realistic.

The same books that ABEM colleagues used were used to pass the ABPS BCEM exams.

ABPS tests were better in my humble opinion than the sample ABEM tests because the ABEM tests had extremely uncommon cases that you really don’t see in real life. These tests were way too academic and trying to be hard in a useless way.

Training in EM residency is better for EM work. I saw the thought patterns and communications of EM residents and attendings where I did away rotations as an fm visiting resident being more fitting to working at EDs, obviously.

EM residencies are better than FM residences more often than not in getting you prepared to work at EDs. Neither is quite adequate if your definition of adequate means working smoothly without referring to books, UpToDate, etc.

I have also worked only at EDs for the last ten years or so after FM residency. I did a sort of an advanced EM fellowship after residency. Prior to the fellowship, as an fm senior resident, I had worked solo at a tiny rural ED as an fm resident after doing all my electives in EM and spending off hours in OR and ER learning EM procedures. I’m now one of the governors for AAEP (separate arm of ABPS for EM). And I believe that ABPS BCEM is important to us and our patients.

Try to not get bogged down by who should be called board certified EM doctors: extremely important to some ABEM EM doctors who are vocal that they and ABOEM doctors are the only ones who can say this. In reality, doctors who treat patients in EDs the best way possible are better EM doctors whether from surgery or IM or FM or EM residency or etc.

ABPS BCEM which you can take only after six years of full time EM work in CA (if you haven’t done an ABPS EM fellowship) forces you to review and refine the practical information needed to help your patients in EDs. It is super important and helpful in treating your patients.

If you get hung up on how others view or call you (you’re not able to call yourself board certified emergency doctors in CA if you’re ABPS BCEM but you can call yourself an emergency doctor. Weird, isn’t it) then you will have a complex or a chip on your shoulder for the rest of your career.

It’s ok to feel that way.

It’s also important to know that being a true great doctor often comes with great sacrifice of yourself. As an FM residency trained EM doctor, you owe to yourself and your patients to study and read and think and review your EM cases. You should know that your EM residency trained doctors are better trained than you but not always. Learn from them. Learn from other non Em residency trained, great EM doctors. Learn from other staff who may not be doctors. Make sure you don’t take everything “they” tell you to be better or worse than your thoughts or gut instincts or knowledge. It’s a fluid process. Art. Art based on reflecting your and others’ prior cases and learning from them.

You must know to dose medications differently for septic shock patients with borderline BP before intubating them. Laryngoscope can truly be a murder weapon for a thoughtless Em doctor. (S. Weingart).

As an FM residency trained doctor who will work as an emergency doctor, you must study more than other colleagues who are trained in EM residency.

I do see myself sometimes ordering more studies and tests and admitting more patients than some EM residency trained doctors. But compared to many other EM residency trained doctors, I order less and admit less.

Point is not that admitting less patients and ordering less tests are signs of better EM doctors. Point is what is right for the patients. And then the flow of ED. But if you’re consistently admitting more and ordering more tests than your EM residency trained colleagues, you better ask them how they’re able to be more efficient and reformat your own hardware.

I still have lots to learn but it’s easier now to work as an emergency doctor after ten years of full time EM work.

You can and will be a great EM doctor after FM residency. Provided that you understand you comparatively know less vs EM or general surgery or orthopedic surgery or ENT or urologist or OB GYN etc working as an emergency doctor in certain things AND provided that you promise to yourself and your patients to study more and learn more and think more and do more shifts to see more patients.

Reward is great. And only you know this. If you are aware of your weak points and work to improve without harming patients, which is easier said than done, and stay HUMBLE your entire career, you will definitely be better than EM residency trained doctors.

My two cents.
 
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Depends on what type of ER. A level 1 trauma center, FM training alone is probably not enough. But in a rural hospital setting FM training alone is fine.

I'm trained as FM, also did 2 years of surgery and worked in ER settings for over 15 years. My surgical and ICU training really came in handy on several occasions. But for the large majority of cases, I found that my FM experience was far more useful. Reason is that EM docs don't really know how to handle routine outpatient care. As a FM you are trained on this. 95% of what you see in the ER is not an emergency.

You will face a lot of issues getting hospital privileges in bigger ERs unless you are BCEM. But if you are willing to work in rural settings, I say go for it.
 
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Don't ask yourself if you're ready to handle the garden variety stuff. Ask yourself if you're ready to manage the crashing 2 y/o kid who was found in a pool or the pregnant woman with altered mental status and belly pain who was just in a MVA.
 
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Out of curiosity, at this point in time, why would you do an FM residency if you're interested in working primarily in an ER? I can understand that this was a "backdoor" entry into EM in the past, but EM residencies now are incredibly not competitive. Something like 40% of slots didn't fill last year.
 
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Because then you’re trapped into a career of mostly ER.
 
Out of curiosity, at this point in time, why would you do an FM residency if you're interested in working primarily in an ER? I can understand that this was a "backdoor" entry into EM in the past, but EM residencies now are incredibly not competitive. Something like 40% of slots didn't fill last year.
For me, medicine was always a side-gig. I've worked in pharma R&D for 20+ years. Research was always my main job. Working in the ER made the most sense to keep up my skills, as it was shift-work, and I didn't have a panel of patients to handle. I could work as much or as little as I wanted.

I also started moonlighting as an ER doc during my FM residency. This was in rural Texas, and they were desperate for docs. So I never had a problem finding shifts. Over time, and as I moved to the northeast, I found that many hospitals insisted on BCEM for privileges. I worked in several smaller hospitals, but eventually gave up my ER privileges.

There are lots of reasons why FM would want to work in the ER. More money, more flexibility, less hassle.
 
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Appears to be adequately answered here in a way but there's not a lot of discussion on this board so here's my opinion as well:

Depends. You could do a few extra rotations in various ERs, surgery rotations, and seek out procedures along the way and probably feel equipped for most ER work but it's a bit of a risky transition if you're planning to work full time in a busy ER alone somewhere.

I have filled in a few rural ER shifts when they absolutely do not have a provider. But if someone came needing a chest tube or intubation I will certainly be calling in my colleagues to help out. If you're serious I suggest ATLS certification and getting an ED mentor. You should form bonds with the ED staff so they call you in when interesting stuff is going down. You'll want to feel very comfortable intubating, central lines, chest tubes, codes, etc. etc.

The mindset is also different as you will need to learn how to put on the ED hat and put down the PCP hat. I continue to be surprised by the random legit emergency I can find with a CT scanner when someone otherwise is very well appearing.
 
Depends on what type of ER. A level 1 trauma center, FM training alone is probably not enough. But in a rural hospital setting FM training alone is fine.

I'm trained as FM, also did 2 years of surgery and worked in ER settings for over 15 years. My surgical and ICU training really came in handy on several occasions. But for the large majority of cases, I found that my FM experience was far more useful. Reason is that EM docs don't really know how to handle routine outpatient care. As a FM you are trained on this. 95% of what you see in the ER is not an emergency.

You will face a lot of issues getting hospital privileges in bigger ERs unless you are BCEM. But if you are willing to work in rural settings, I say go for it.
So far today, rural ED, 2/3 of what I've seen the clinic would absolutely turn away and send here and the other 1/3 wouldn't be able to get into clinic today anyway.
 
why don't FM docs who want to work ER partner with ER physicians
85% of the cases in most ER can be handled by FM doc
and the ER doc can handle the other 15%
its a win win for everyone
 
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