Four Specialties Show A Decline In Applications

[Osteoth]

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I imagine it's a highly lucrative outpatient field for the psychiatrists that treat the 125M Americans who make over 100K / year. Or the ~50M people who make 150K / year. For the rest of the nation it's piss-poor coverage and they all wander around psychotic listening to space messages from their radio transmitter embedded in their tooth

Aka whats happening in the rest of medicine. Psych is different because it’s harder to just follow an algorithm and prescribe a medication.

Most midlevels and other docs even can’t just pick a diagnosis and give a pill in a 15 minute visit.

 

[Old_Mil]

So, how do we get a psychiatric fellowship for EM grads started?

 

[VA Hopeful Dr]

So, how do we get a psychiatric fellowship for EM grads started?

Residency Navigator Directory: Psychiatry

Find the best residency program for you. Read reviews and see ratings from program alumni.

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[HemorrhagicShock]

Residency Navigator Directory: Psychiatry

Find the best residency program for you. Read reviews and see ratings from program alumni.

www.doximity.com

Ha - I don't think anybody here is willing to go through a 4 year slog of a residency after finishing EM and becoming an attending. Granted, I hear psychiatry residency is a fairly 9-5 40 hours per week sport...

 

[RustedFox]

Ha - I don't think anybody here is willing to go through a 4 year slog of a residency after finishing EM and becoming an attending. Granted, I hear psychiatry residency is a fairly 9-5 40 hours per week sport...

Yeah.
That's the thing. We as EPs need fellowships that allow us more mobility. The job is really broad spectrum as it is. To be able to go do some outpatient medicine is ideal. Our medical knowledge is vastly more robust than the PLPs, who flit between whatever they want to do whenever they like and do those things poorly. Better for physicians, better for patients.

I'll get out there and say that I would totally 1-1.5 years of fellowship to do outpatient things. While I already can do those things better than a PLP, I recognize the need for training because I'm not Dunning-Krugered.

 

[VA Hopeful Dr]

Yeah.
That's the thing. We as EPs need fellowships that allow us more mobility. The job is really broad spectrum as it is. To be able to go do some outpatient medicine is ideal. Our medical knowledge is vastly more robust than the PLPs, who flit between whatever they want to do whenever they like and do those things poorly. Better for physicians, better for patients.

I'll get out there and say that I would totally 1-1.5 years of fellowship to do outpatient things. While I already can do those things better than a PLP, I recognize the need for training because I'm not Dunning-Krugered.

I think I've said this before (though maybe just in my own head). I don't have any major objection to a fellowship option that would produce EPs that could do primary care well. I'm not sure how much enjoyment you would get out of the work, but that wouldn't make you an unsafe doctor so that's not a big concern of mine other than concern for you folks as fellow physicians.

But the petty part of me can't help but recall all the threads where many of y'all were quite unpleasant to FPs wanting to do an EM fellowship and go work in an ED.

 

[RustedFox]

I think I've said this before (though maybe just in my own head). I don't have any major objection to a fellowship option that would produce EPs that could do primary care well. I'm not sure how much enjoyment you would get out of the work, but that wouldn't make you an unsafe doctor so that's not a big concern of mine other than concern for you folks as fellow physicians.

But the petty part of me can't help but recall all the threads where many of y'all were quite unpleasant to FPs wanting to do an EM fellowship and go work in an ED.

Good post.

You know I love your presence and contributions here. In no way am I trying to be adversarial (in case any of this doesn't come across correctly).

Your point of "FPs wanting to do an EM fellowship and go work in an ED" is well-received. My two main complaints about every FP that I've worked with in the ED are:

- They don't have the EP "twitch reflex" that identifies those with underlying badness that hasn't yet bubbled to the surface. Similarly, they don't have the "defense against the dark arts" skill, and get into the "escalating doses of dilaudid and time" game when really, the chronic abdominal/back/headache pain patient needs to GTFO.

- They're procedurally lacking. I'm done putting in chest tubes and central lines for the FP because they're "not comfortable", and I'm really, really done with taking them aside and letting them know (following the above point) things like: "If you don't tube and line this patient fast; he's going to code."

Can these skills be taught via fellowship ? I dunno. Maybe. I haven't seen it yet; though that doesn't mean that it doesn't exist. I'd sure as hell take a FP with fellowship in the ED over a Jenny McJennyson, NP ABC-123. Right now, the nation needs more and more FPs, and less and less Jenny McJennysons. Myself, and hundreds of other board-certified EPs will be happy to step into that role so that the Jennys out there can't screw things up more.

 

[Osteoth]

Good post.

You know I love your presence and contributions here. In no way am I trying to be adversarial (in case any of this doesn't come across correctly).

Your point of "FPs wanting to do an EM fellowship and go work in an ED" is well-received. My two main complaints about every FP that I've worked with in the ED are:

- They don't have the EP "twitch reflex" that identifies those with underlying badness that hasn't yet bubbled to the surface. Similarly, they don't have the "defense against the dark arts" skill, and get into the "escalating doses of dilaudid and time" game when really, the chronic abdominal/back/headache pain patient needs to GTFO.

- They're procedurally lacking. I'm done putting in chest tubes and central lines for the FP because they're "not comfortable", and I'm really, really done with taking them aside and letting them know (following the above point) things like: "If you don't tube and line this patient fast; he's going to code."

Can these skills be taught via fellowship ? I dunno. Maybe. I haven't seen it yet; though that doesn't mean that it doesn't exist. I'd sure as hell take a FP with fellowship in the ED over a Jenny McJennyson, NP ABC-123. Right now, the nation needs more and more FPs, and less and less Jenny McJennysons. Myself, and hundreds of other board-certified EPs will be happy to step into that role so that the Jennys out there can't screw things up more.

Your first bullet made me laugh haha

 

[VA Hopeful Dr]

Good post.

You know I love your presence and contributions here. In no way am I trying to be adversarial (in case any of this doesn't come across correctly).

Your point of "FPs wanting to do an EM fellowship and go work in an ED" is well-received. My two main complaints about every FP that I've worked with in the ED are:

- They don't have the EP "twitch reflex" that identifies those with underlying badness that hasn't yet bubbled to the surface. Similarly, they don't have the "defense against the dark arts" skill, and get into the "escalating doses of dilaudid and time" game when really, the chronic abdominal/back/headache pain patient needs to GTFO.

- They're procedurally lacking. I'm done putting in chest tubes and central lines for the FP because they're "not comfortable", and I'm really, really done with taking them aside and letting them know (following the above point) things like: "If you don't tube and line this patient fast; he's going to code."

Can these skills be taught via fellowship ? I dunno. Maybe. I haven't seen it yet; though that doesn't mean that it doesn't exist. I'd sure as hell take a FP with fellowship in the ED over a Jenny McJennyson, NP ABC-123. Right now, the nation needs more and more FPs, and less and less Jenny McJennysons. Myself, and hundreds of other board-certified EPs will be happy to step into that role so that the Jennys out there can't screw things up more.

If you look back, I actually agree with what you've said here most of the time and have said as much before (though I don't expect you to have my posts memorized by any stretch so don't take this as any kind of criticism).

I also don't think there are very many EPs who have changed to the PCP route. I've never met one outside of urgent care and so have no personal experience of any EP trying it. Just pointing out the role reversal here.

 

[The Knife & Gun Club]

Ha - I don't think anybody here is willing to go through a 4 year slog of a residency after finishing EM and becoming an attending. Granted, I hear psychiatry residency is a fairly 9-5 40 hours per week sport...

When I was in Med school we had a psych fellow who picked up ED shifts a few times a month in the psych area of our ED. He made ED rattending pay. IIRC he was making about $60,000/year resident salary and another $100,000/year attending salary working 4-6 moonlighting shifts per month.

So not EM attending money but $160k/year is much more financially palatable than $60k. Just a thought.

 

[Apollyon]

When I was in Med school we had a psych fellow who picked up ED shifts a few times a month in the psych area of our ED. He made ED rattending pay. IIRC he was making about $60,000/year resident salary and another $100,000/year attending salary working 4-6 moonlighting shifts per month.

So not EM attending money but $160k/year is much more financially palatable than $60k. Just a thought.

And how did that make you feel?

 

[Brigade4Radiant]

EM doctors would be better served to get an NP degree and then being able to have more mobility

 

[hebel]

That doesn’t explain the decline in the FM or psych applications, they’re doing well as a whole with a decent job outlook.

For psych, I would guess that's because it no longer is the "easy" bottom of the barrel default back-up specialty it used to be, so you get less people applying to it as a back-up.

 

[BorntobeDO?]

If you look back, I actually agree with what you've said here most of the time and have said as much before (though I don't expect you to have my posts memorized by any stretch so don't take this as any kind of criticism).

I also don't think there are very many EPs who have changed to the PCP route. I've never met one outside of urgent care and so have no personal experience of any EP trying it. Just pointing out the role reversal here.

I know of one who went full PCP for his own practice. He said it was difficult to get empaneled to insurance, but he was in a need area so he did get it done. I agree that a 1 year outpatient fellowship would likely be sufficient for EM to do outpatient. There is a lot of overlap.

 

[Brigade4Radiant]

EM is more acute and people can die. Primary care can mess people up but it is more detailed oriented. You also have to know screening criteria but you can learn as you go

NP and PAs do it and claim they are just as good as physicians

 

[nexus73]

Psych is fine but you have to spend time with patients to do a decent job, so you can't see 40+ patients a day like a derm or optho. So income is limited just because of the time needed. And cash pyschiatry practices get discussed but they're pretty hard to setup full time and it's usually only viable in major metro areas with lots of high earning households. Even then it's hard to do full time. Most psychiatrists end up in private practice or employed outpatient jobs making about $225-275K for full time work.

 

[VA Hopeful Dr]

I know of one who went full PCP for his own practice. He said it was difficult to get empaneled to insurance, but he was in a need area so he did get it done. I agree that a 1 year outpatient fellowship would likely be sufficient for EM to do outpatient. There is a lot of overlap.

My only concern with a single year is that's not very long in the continuity of care spectrum. There's a reason FM residencies require you to have 2 years of continuous management of your patient panel. As that's the main aspect of FM training that EM-trained physicians would be lacking, I'm not sure that's the area you really want to skimp on.

 

[anbuitachi]

surprised anesthesiology getting so many more applications since its a dying field

 

[Osteoth]

surprised anesthesiology getting so many more applications since its a dying field

Depends on what your expectations are if it’s dying

 

[Candidate2017]

I imagine it's a highly lucrative outpatient field for the psychiatrists that treat the 125M Americans who make over 100K / year. Or the ~50M people who make 150K / year. For the rest of the nation it's piss-poor coverage and they all wander around psychotic listening to space messages from their radio transmitter embedded in their tooth

This is false.

The Medicaid population within every community has a budget of a gazillion dollars funded by your taxes. Sometimes a bigger budget than your local public schools. They get extensive wraparound services: psychiatrist, primary care doctor, social worker, therapist, housing, transportation, detox, SSDI filing assistance etc (we're not even counting free ambulance rides, ED visits, sammiches and CTs).

The problem is "Murica, you can't tell me what to do when my court ordered treatment expires." In reality, we could have much better outcomes for much cheaper, simply with a monthly helicopter that hovers over the local squatters' camp and delivers antipsychotics via sniper dart.

In sum, there's many resources that patients refuse to utilize but will continue to be funded because there are lots of hands in the taxpayer till. In contrast, you, fancy doctor, can use your fancy health insurance or even pay $1000, and what you get is... a psychiatric appointment. That's all you get. You get no handholding. This is why I would hazard to say the suicide rate among doctors (and middle class people with health insurance) is actually higher than the trainwreck "psych" patients you see in the ED.

 

[Old_Mil]

EM to PCP is much more doable if that PCP work completely excludes OB work. When I was looking at residencies, many FM residencies were very OB heavy. The PITA would be getting all the insurance preauths done and keep in mind that employed FM physicians are every bit the galley slaves that CMG contracted 1099 EM docs are. One of the things that discouraged me from going the FM route was seeing just how beaten down PMDs were dealing with the 15 minute shot clock and the stack of charts sitting on their desk at the end of a clinic day. One of the problems we have with an exit strategy is the degree to which midlevels have taken over urgent care work.

 

[Lexdiamondz]

I know of one who went full PCP for his own practice. He said it was difficult to get empaneled to insurance, but he was in a need area so he did get it done. I agree that a 1 year outpatient fellowship would likely be sufficient for EM to do outpatient. There is a lot of overlap.

I don't really think a year of outpatient medicine would be enough to get the nuance of being a good PCP

Nevermind the non-clinical aspects of working in the outpatient setting. Much like a year isn't enough to learn EM for an FP, a year probably isn't enough for an EP to learn FM.

Although the cynic in me wants to think that the ACGME exclusively views residents as cheap worker bees, there's probably a really good reason why combined EM-FM and EM-IM programs are usually around 5 yrs long. Sure, there's a lot of overlap between the respective fields but there are huge differences in mindset that take time to really appreciate.