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Discussion in 'Family Medicine' started by kwooder, May 5, 2004.
Does anyone know if there is such a thing? These are the two main areas I am interested in.
There are a few DO FM/EM programs. I don't know if there are any Allo FM/EM programs.
do a search for the american college of osteopathic emergency physicians. I think it is www.acoep.org
they list all the fp/em programs on their site. I think there are 4. they are 5 years long.
There is one program in Tennessee that offers a one year ER fellowship. After the fellowship you sit for some set of boards (from my knowledge it is not the same boards people who do straight EM sit for, but you are still board certified for whatever that's worth). I can't remember the name right off, but it shouldn't be to hard to find.
no allopathic combined fp/em programs yet. they are in talks at the moment. there are a few d.o. programs out there though.
What you are talking about is the American Board of Medical Specialists (or some other sort of name). You pretty much can be "boarded" in whatever specialty... however, its more of a loophole, and often you are not recognized as the "specialist." Some rural EDs will recognize you for it, but in the near future I have a feeling JCAHO and the Hospital Lobbyists will require all physicians who work in the ED to be ABEM or ABOEM certified, as there are studies proven we are more efficient, safer, and provide better care in the ED than anyone else. If you want to go EM, then do an EM or combined EM program.
What studies are you referring to? In other words, where can I find them? I don't think it will be logistically possible for every ER in the US to be staffed by a board certified ER doc 24/7.
Maybe not today, but the day is coming.
maybe one day in the ideal world. but, there are lots of small hospital er's out there that will continue to be staffed by FP's. Texas, Florida, and California are prime examples. Large land masses (well maybe not florida, but FL has several small towns) with lots of rural ER's. there is a predicted shortage of residency trained EM docs for the next 12 yrs. Until then and radical health care changes..maybe. but, again...your not going to get these EM trained guys out in rural areas for $65/hr. PERIOD!
I understand there is some talk about creating one, but right now there isn't, for allopathic residencies. Only osteopathic. Too bad, seems like theres a lot of overlap.
I do't mean to piss off any EM guys, but there is no way that it will ever be commonplace for board certified EM docs to staff rural hospitals. Hell, any doc is difficult to get in a rural hospital in some places. In some areas, rural FP docs run the ER but only show up when a patient arrives and gets triaged by the nurse. The ER's function this way because they obviously don't have the revenue to afford ANY full time doc, much less an EM boarded one. And to be honest, as much as this will piss of some of you, the reality is that many FP docs can provide nearly the same level of care "rurally" because they are used to the setup there. Try taking some board certified EM doc and have them function with one nurse and a medical assistant in a code. EM docs are used to the great staff and facilities and with that comes complacency. Try running a code as the only person who really has a clue what is going on, meaning you do the IV, you do the tube, and you do it all!!! This totally sucks, but I feel as a paramedic of 10 years plus that I am equiped to work under these stressors while some EM docs are used to just shouting orders and dropping the tube. Its different out in the sticks and many FP's have been running the show there for decades before there was even an EM profession.
i couldnt agree more! not to mention that mostly what comes in the big city er's is chronic primary care conditions anyhow. very little is the truly multiple trauma pt and codes left and right. these do happen but mostly in the few inner city hospitals. these em guys are hilarious...there is a world outside the er.
Actually, talking ot my attendings (who are young, BC EM physicians), they have told me they can make just as much in the "dinky rural ED's" that they can where they are now. They have told me they'd be making 200-250k a year, with 2 year partnership, at many small rural EDs. They decided to stick with the big gun hospitals because it was a lot more fun and they'd see a lot more.
They also said they woudl be seeing a LOT less patients and would have it "easy."
Granted, these small rural EDs are in FL... so I'm not sure if its the same all over the US.
Actually, as house officer at the program I'm at, that's happened quite a few times. I've intubated, ran the code whiel I intubate, then immediately start a central line, as well as do a bedside echo (if an u/s machine is available), and run the code for however long it takes. ANd I'm just an EM intern. EM people are the most versatile and useful peopel to have in the hospital. Of course this is "IMHO."
I'm from rural central Kansas and have a pretty good relationship with several ER docs. Here's what I know about their income:
Docs at 180 bed community hospital, all FP or IM (one med/peds). 12 hrs shifts. 40-50 pts seen in the ER per day. Income is $150/hr, but no benifits/insurance paid
Docs at 55 bed community hospital; 4 total, 3 FP, 1 EM BE. 24 hour shifts. 10-20 pts a day (20 being an unusally busy day). Often get to sleep through the night. 225k/yr w/benifits. not sure about insurance
Docs at 13 bed community hospital (yes, 13 bed). Only on call coverage split between three MD/DO's (all FP or IM) and 3 PA's. Docs are employed by hospital and run rural health care clinic during day. Very few patients seen in ER. Pay is by call nights w/bonuses for having to go in. Insurance/benifits provided.
I think that everyone would like to have a BC/BE EM physician when they go to the ER, but it seems like that it will be awhile before that happens here in Kansas. Pay is good, but even at the largest hospital (seeing 40-50pts a day) the case load is honestly pretty lame. A lot of dump-and-run by nursing homes as well as a lot of stuff that should be handled by PCP (luckily we have them!!!). In the year I've been shadowing there I've seen 2 tramuas and only a handful of codes.
Q, when you finish up residency, I know a couple hospitals that could use a good BC EM guy
J Emerg Med. 2000 Aug;19(2):99-105.
Malpractice occurrence in emergency medicine: does residency training make a difference?
Branney SW, Pons PT, Markovchick VJ, Thomasson GO.
Denver Health Residency in Emergency Medicine, Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.
PMID: 10903454 [PubMed - indexed for MEDLINE]
I was talking to a NYU trained EM physician. He feels EM trained guys will not
fully saturate the ER market because usually ER physicians last a good 15 to 20 of work life...And there are not enough EM trained guys around to staff the entire nation's ER.
An FP can complete this residency do maybe three months of EM elective during last year of FP residency.
Then he or she can go to Tennesse for EM fellowship.
Once you have that year completed..in many EMs will accept you to do ER work. I know of few ERs in NY that do not require EM training to work in their ER.
Most rural ED's are not staffed by EM docs. And some of them can be quite scary, while others are quite good. I remember as a paramedic, I used to volunteer on this squad way out in the sticks where they had a 10 bed hospital staffed by this Russian lady doctor who knew ACLS about like I knew nuclear fission. I remember one time in a code I had brought in that she arc's the paddles and nearly killed a couple of us!! I also had to kindly remind her of basic algorithms like not using lidocaine in PEA, and to use epinephrine 1/10,000 IV and not the 1/1000 form. She was lost. It often takes a team effort of RN's, docs, and medics to keep a rural ED somewhat safe at best. But then there are rural ED's staffed by excellent FP docs and these places are mirror images of city ED's. To me the best idea of all is to have rural ED's staffed by FP's linked to telemed where some ED doc who has the system set up on his laptop at home can communicate 24/7. Best of both worlds!! I mean that's what medicine is coming to these days. I would say in 10 years there will be very few radiologists working anywhere but at home.
I like the study that is posted in an Emergency Medical Journal by likely emergency room physicians as editors and as priniciple investigators. Thanks for that unbiased reference .
Could someone please post a link to the combined programs or list them. I couldn't find them from the ACOEP website.
There is only three or four of them. One in Grandview Ohio, another in New york, another in Michigan, and the last one in Illinois, Chicago.
Go to DO-online.org. Search under student and resident resources. Click on opportunities or listing of residencies. I believe you do have to register in order to get up to date info. If you don't register, there is still info available in pdf format.