FP in the ER

[halodoctor]

---

Members do not see this ad.

.

 

[deleted87716]

i was wondering if people could mention what are the chances i could work in an ER after doing a residency in FP?

You'd probably only be able to do this somewhere that had difficulty recruiting board-certified EM docs, e.g., a rural area.

is this common?

As the number of board-certified EM docs increase, it's becoming less so.

what would be the negative thing about doing this? (aka working both fp and er)

Nothing comes to mind, other than the lousy hours, higher malpractice, and all of the other negatives of EM in general.

 

[boboli]

I also had the same dilemma and ultimately decided on FP. Many rural ERs are staffed primarily by FPs. Sometimes this is in addition to clinic/hospital duties. Other times the FPs only work in the ED. I've talked to several of these FPs. Even the ones who have worked in EDs their whole careers can't get jobs in larger (Level II/I) EDs. On the other hand a lot of small hospitals actively recruit FPs to work in the ED.
Anyone correct me if I'm wrong, but I think working as an FP in an ED in a larger city is not realistic. But if you want to work in a rural area, it is definitely a possibilty.🙄

 

[iatrosB]

But if you want to work in a rural area, it is definitely a possibilty.🙄

Agreed. 👍

If you want to do EM and live in a large/medium sized city...go EM.

If you don't care or even want to live in a tiny town...go FM.

It is really common in the rural areas, but keep in mind as EM cranks out new grads (it is one of the most popular residency choices), they will eventually migrate to even the rural areas...but you're safe for awhile.

 

[Tn Family MD]

For what it's worth, there is at least one FP doc that I know of that works at our level I trauma center in the ER. That is in Knoxville, Tennessee which I guess some would consider a larger city and some would not. As an aside, our ER is staffed by Team Health, the (by far) largest provider of staffing for ER's in the country. So, there is at least some amount of FP docs still working at somewhat larger centers that provide higher level care. Don't know if that helps. Also an interesting note, we have an ER fellowship associated with our FP program here at UT-Knoxville that the Team Health docs provide the attending coverage for. For the last several years, every single doc that has completed the fellowship has been hired on with Team Health at the end of their training. Basically, it functions as a try-out for Team Health in a way to make sure they get along with you and that you are competent.

 

[PowderHound]

Halodoctor-

I am having the same FM vs. EM dilemma myself. As third year winds down, I hope I will figure it out. I have a month of EM scheduled in July, so we'll see how that goes. It just love the variety of both fields, and while I love the "acute" stuff in the ER, I also think I would enjoy really getting to know patients over their lifetime. Let me know how it goes!

Powderhound

 

[BMW19]

http://www.aafp.org/fellowships/other.html

Go to this website and scroll down. I believe there are 5 1 year approved fellowhips in EM off of FM. Granted, this may not give u the same status as a board certified EM doc but maybe a last resort? Some hospitals would prob. give u a second look over a regular FP doc.

Hope this helps.

BMW-

 

[halodoctor]

thanks BMW

there are only 4, one is in oklahoma and the other three in tennessee... woohooo!

ugh, maybe in 4 years there'll be more?

i totally get what you are going through powder, i'm so into the acute stuff and also equally into the longterm care...

today, i was working with a family resident in ob/gyn who drove me NUTS! this girl could not figure out the ultrasound machine if her life depended on it. sometimes i get so frustrated working w/ family residents because on the average they are the less competent ones. but then again, everyone we passed in the hospital gave her this warm smile and said hello.

i know there are days when i would completely respect the smiles more than the skills... but today just got to me because she kept repeating the same mistake over and over again... anyways, just some random thoughts.

 

[Apollyon]

For the last several years, every single doc that has completed the fellowship has been hired on with Team Health at the end of their training. Basically, it functions as a try-out for Team Health in a way to make sure they get along with you and that you are competent.

Not true. How do I know? Because one of the grads works with me now - definitely NOT TeamHealth.

Our EM group in the south actively recruits FM grads - about 25 or so of the 46 docs in the group are EM trained, and there are at least 2 FM folks coming on board in July. With one exception, the FM people work only fast track or in the intermediate-level ED. With enough hours in, the hospital will credential non-EM people to work single-cover and for critical care skills/level shifts. However, irrespective of any of that, the non-EM people are not partnership-track.

 

[anes_asmaj]

I am premed and volunteer at SHANDS/UF ED. The physician in charge of minor care section of the ED is from FM. The main adult section is all staffed by EM trained physicians. SHANDS is level 1 hospital. He is awesome and very willing to explain and show everything that he does.

 

[Tn Family MD]

Not true. How do I know? Because one of the grads works with me now - definitely NOT TeamHealth.

Our EM group in the south actively recruits FM grads - about 25 or so of the 46 docs in the group are EM trained, and there are at least 2 FM folks coming on board in July. With one exception, the FM people work only fast track or in the intermediate-level ED. With enough hours in, the hospital will credential non-EM people to work single-cover and for critical care skills/level shifts. However, irrespective of any of that, the non-EM people are not partnership-track.

Well, I am certainly not the administrator of the program here, only a resident. And I am just telling you guys what I was told on my interview here. Being that I personally am not interested in the EM fellowship, I didn't really pursue any further questions on that part of the program or ask for further information. Maybe I have been misinformed or misunderstood what I was told. If you don't mind sharing, what year did said physician graduate from the program?

At any rate, the nuts and bolts of it are that there are places where FM docs work in ED's, particularly rural locations with lower acuity type stuff. At times, even in places like university settings. But, if you want to practice EM, you should do an EM residency. If you might want to do both, maybe an FM residency followed by an EM fellowship is right for you. Or there is at least one FM/EM combined program for residency with more reportedly on the way. Perhaps that would be ideal if you rally had your heart set on doing both.

 

[deleted109597]

At any rate, the nuts and bolts of it are that there are places where FM docs work in ED's, particularly rural locations with lower acuity type stuff. At times, even in places like university settings.

Yes, FM does run the rural ones, and many of them do it well. However, not all rural stuff is low acuity, which is why ABEM is on their BC/BE kick. I can almost guarantee you that there will not be an FM boarded doc getting a new university position at any level 1 facility in the future. There may be some doing it now, but when they retire (or are encouraged to leave) they will be replaced with EM docs. It is just going to happen. Right now I work with an FM doc who runs the EMS in a rural county, so I know they can do it well, but the future for urban and semi-urban places is EM. Not even EM fellowed FM, because that isn't a boarded (or recognized boarded) position.

But, if you want to practice EM, you should do an EM residency.

Absolutely. Unless you can't get into one, then maybe you could do FM and only work rural places. People do it every year, and some FM programs promote it (while others detest it).

If you might want to do both, maybe an FM residency followed by an EM fellowship is right for you. Or there is at least one FM/EM combined program for residency with more reportedly on the way. Perhaps that would be ideal if you rally had your heart set on doing both.

Except that said EM/FM filled exactly 0 of their spots with the match this year. Now, that may have been a mistake on their part, and it is likely that more places will spring up in the future. However, not many people who do one area are likely to do the other regularly. Most people work 1 full time job, not 2 half-time jobs. Dual boarded physicians are an odd commodity out there, and not many people know how to utilize them yet. However, if you dig it, go for it.

 

[divinity09]

thanks BMW


...sometimes i get so frustrated working w/ family residents because on the average they are the less competent ones. but then again, everyone we passed in the hospital gave her this warm smile and said hello.

i know there are days when i would completely respect the smiles more than the skills...

wow. way to insult this entire forum.

 

[iatrosB]

wow. way to insult this entire forum.

That was my thought 👎

 

[corpsmanUP]

This topic seems to regenerate about twice a year around here. Undoubtedly you can go FM and find an EM position. The sad reality of it though is that it will become harder and harder, and you will be looking over your shoulder in every job to wonder when the EM doc is going to replace you. Then you will finally corner yourself into one position and it will be virtually impossible to leave it and find a new job.

A lot of the FP docs working in EM are older guys with true ABEM board certifications through the last chance exam given back over a decade ago. These guys are basically equivalents and are pretty safe. But this pathway is not open any longer.

The worst part about FM docs working in the ED is that your learning curve comes at the expense of patients over your first few years. As an EM resident, my learning curve has a distinct safety net with my attendings and upper levels being around to help me. But by the time I am done, I will have done over 20 months of ED work, 6 months in critical care settings, and other ED specific rotations. The average FM program does 1-2 months in the ED and perhaps a motivated FM resident could spend a few more on electives. But that is not enough. Our interns are more competent I assure you to take care of critical patients in the 2nd half of their intern year than a boarded FM doc who just graduated from residency.

And worst yet, the FM doc will probably be relegated to the rural jobs, where they will have NO backup when they can't get the intubation, can't get the chest tube, can't get the central line, etc...etc...

The FM pathway is just a terrible route in general to work in EM, and the fellowships, although helpful obviously, do not give any additional board certification and offer no real hope to the average FP wanting to work in EM.

My guess is that the combined EM/FM programs will become pathways for those who cannot get EM alone, so they will use it as a backup. It is certainly better than not getting the training, but it will be a very long path and a painful one!!

 

[halodoctor]

😀

That was my thought 👎

I'm sorry, I didn't mean to be rude and that comment was better kept to myself, but now that it is out, I'd rather explain myself than take it back.

FM is one of the easiest residencies to get into. You don't have to score 250 on your boards to get into FM and the majority of FMs don't because if they did, they'd be doing something else and making twice as much money.

There are the altruists here who would claim that they would do FM no matter what, but this is a question of chicken vs the egg. In more detail, if one is satisfied with FM, are his/her board scores low because it's easy to get into FM, OR are one's board scores low due to their inherent nature, which naturally JIVES with FM??? AHA! To be or NOT to be!!!

Ok, I hope that paragraph made sense to at least one other person than myself. In any case, I'm not insulting FMs. I WANT to become and FM! Still, I've worked with FMs at the lower quality of training programs (thanks to being in a mediocre medical school myself and lacking the opportunity to work in better settings), and I can objectively say that these people frustrate me.

It took this FM resident about an HOUR to figure out how to do an AFI on the ultrasound machine. I consider myself a patient person, but I was ready to pull out the hair I had left in my head. Actually, though, now that I think about it, it wasn't her incompetence that got to me. It was the fact that she blamed me in front of the attending for not getting the stickers which was her duty along with getting the patient. So I was upset that she didn't have the guts to take responsibility, especially when I had covered for her when she continuously pressed the wrong buttons on the ultrasound machine.

And there you have it folks, my lengthy shuffle step... hope I was able to explain myself a little better! 😀

 

[Tn Family MD]

Our interns are more competent I assure you to take care of critical patients in the 2nd half of their intern year than a boarded FM doc who just graduated from residency.

Ha ha. I had a good laugh out of this one right here.

Oh and to the other guy that had to lash out and act like I didn't know what I was talking about, I'd just like to clarify to the forum that he sent a private message admitting that the dude he works with from our program did graduate just last year, which just happens to be after I was told about the whole Team Health thing I referenced above.

The bottom line is this is a turf war, one thing that FM docs are used to unfortunately. There are bunches of EM docs that are worried about their precious turf, and probably deep down know that they really aren't any more talented than plenty of FM docs that could easily replace them. From my personal experience, the EM docs that staff our ER from Team Health are spectacularly awful physicians. I'd say the only doctors in our entire facility that know less about managing medical problems are the OB/Gyn docs, who still use methyl-dopa for blood pressure control for christ's sake.

Get over it, fellas. Plenty of docs out there can do what EM docs do. In fact, at our hospital, the EM docs don't even see any patient under the age of 21. Those are all seen by Peds docs or Med/Peds trained docs, or sometimes even PA's and NP's. So, you might as well go ahead and dismount that high horse.

 

[Tn Family MD]

😀

I'm sorry, I didn't mean to be rude and that comment was better kept to myself, but now that it is out, I'd rather explain myself than take it back.

FM is one of the easiest residencies to get into. You don't have to score 250 on your boards to get into FM and the majority of FMs don't because if they did, they'd be doing something else and making twice as much money.

There are the altruists here who would claim that they would do FM no matter what, but this is a question of chicken vs the egg. In more detail, if one is satisfied with FM, are his/her board scores low because it's easy to get into FM, OR are one's board scores low due to their inherent nature, which naturally JIVES with FM??? AHA! To be or NOT to be!!!

Ok, I hope that paragraph made sense to at least one other person than myself. In any case, I'm not insulting FMs. I WANT to become and FM! Still, I've worked with FMs at the lower quality of training programs (thanks to being in a mediocre medical school myself and lacking the opportunity to work in better settings), and I can objectively say that these people frustrate me.

It took this FM resident about an HOUR to figure out how to do an AFI on the ultrasound machine. I consider myself a patient person, but I was ready to pull out the hair I had left in my head. Actually, though, now that I think about it, it wasn't her incompetence that got to me. It was the fact that she blamed me in front of the attending for not getting the stickers which was her duty along with getting the patient. So I was upset that she didn't have the guts to take responsibility, especially when I had covered for her when she continuously pressed the wrong buttons on the ultrasound machine.

And there you have it folks, my lengthy shuffle step... hope I was able to explain myself a little better! 😀

My board scores are more than a standard deviation above the national average for the year I took the exam (Step I that is, which I assume you are referring). We have an incoming intern for next year's class with boards just under 250. Not everyone that does FM is saddled with low board scores. That's a dangerous assumption.

 

[sophiejane]

The average FM program does 1-2 months in the ED and perhaps a motivated FM resident could spend a few more on electives. But that is not enough. Our interns are more competent I assure you to take care of critical patients in the 2nd half of their intern year than a boarded FM doc who just graduated from residency.

And worst yet, the FM doc will probably be relegated to the rural jobs, where they will have NO backup when they can't get the intubation, can't get the chest tube, can't get the central line, etc...etc...

I see your point here, but there are so many generalizations...and you know how hard it is for me to keep my mouth shut! 😉

As you know, FM programs vary vastly in quality and level of experience. I would venture to say there there are quite a number of newly graduated FM residents from excellent unopposed programs who could absolutely hold their own in an ED with EM interns who have only got 6 months of training under their belts. 3 year versus 6 months? Come on, that's a bit harsh, especially for someone like you who knows full well the intensity of training and great ER experience at a number of unopposed FM programs.

While I agree with you in the high acuity cases, I'd rather have an EM boarded doc any day of the week. But the majority of patients ON AVERAGE in the ED are not in fact high acuity. FM docs have the time to hone their outpaitient skills and learn to recognize and treat the lower acuity stuff. Would I want them to be the only one on duty in a level 4 (or 3 or 2) trauma center? Hell no. But we all know that doesn't happen.

I have spent a fair amount of time in rural EDs these past few years, and I've seen several chest tubes, intubations, and codes run very competently by FM docs. They stabilize them and ship them, and they do it quite well. Trauma cases are generally not going to be walk-ins, and thus will be life-flighted or taken by EMS to a bigger hospital.

And there are back-ups...the rural hospital I'm at now always has a CRNA present who (no matter what you think about CRNAs) has plenty of experience with intubations. There are general surgeons on call within minutes away who can help with lines and tubes.

As an aside, this hospital in a community of 6,500, about 30 minutes from a city of 200,000 has been looking for a full time EM boarded physician for about a year. The best they have found is someone willing to work only on weekends. Maybe this will change with more EM programs opening, but for now, it's FM docs or nothing out there.

 

[deleted87716]

FM is one of the easiest residencies to get into. You don't have to score 250 on your boards to get into FM and the majority of FMs don't because if they did, they'd be doing something else and making twice as much money...hope I was able to explain myself a little better!

Well, you certainly dug yourself a deeper hole. 🙄

 

[corpsmanUP]

Ha ha. I had a good laugh out of this one right here.

Oh and to the other guy that had to lash out and act like I didn't know what I was talking about, I'd just like to clarify to the forum that he sent a private message admitting that the dude he works with from our program did graduate just last year, which just happens to be after I was told about the whole Team Health thing I referenced above.

The bottom line is this is a turf war, one thing that FM docs are used to unfortunately. There are bunches of EM docs that are worried about their precious turf, and probably deep down know that they really aren't any more talented than plenty of FM docs that could easily replace them. From my personal experience, the EM docs that staff our ER from Team Health are spectacularly awful physicians. I'd say the only doctors in our entire facility that know less about managing medical problems are the OB/Gyn docs, who still use methyl-dopa for blood pressure control for christ's sake.

Get over it, fellas. Plenty of docs out there can do what EM docs do. In fact, at our hospital, the EM docs don't even see any patient under the age of 21. Those are all seen by Peds docs or Med/Peds trained docs, or sometimes even PA's and NP's. So, you might as well go ahead and dismount that high horse.

Both you and SophieJane reference the exceptions and not the norms. After 6 months in an EM residency, most residents have completed 3 months of ED and 3 months of critical care....trauma/MICU/SICU/CVICU/etc...etc..

And I hate to burst your bubble, but admission rates at major academic medical centers range from 25-35% on average, meaning as many as every 3rd patient requires admission. Of the admissions, more than half go to the ICU. So every 6th patient really needs someone competent in critical care and knowledgable about critical care medicine.

Saying the EM docs you work with in your practice get relegated to any particular patient care group defines the scope of the problem in your place. Your EM docs are not the ones running the show obviously and are not the owners of the group practice. That is a trend that will eventually change everywhere. EM docs don't need to know that what the newest outpatient BP regimen is, because they aren't going to be adjusting anyone's outpatient BP meds. We see people for hypertensive urgency or emergency and fix that, and then you guys get to figure out how to manage them long term.

And to address SJ's comment about rural FM docs doing a geat job at EM. That is awesome, and I pat those guys on the back for a job well done. But being in a tertiary hospital in a state a lot like Texas, I can tell you that we receive way more inappropriately managed cases than we do appropriately managed patients. We are the backstop, being a level I ED. I agree that it is hard to recruit EM docs to the rural areas, and I also agree that FM is the best we have currently. But I mean what I say when I state that the first year or two of an FM doc in the rural setting will be a steep learning curve at the patient's expense. And the idea that a rural hospital would always have a CRNA is not likely. Maybe in larger areas, but I assure you in the majority of small level 4 hospitals in our state and other states, that there is no anesthesia presence there after 5PM or on weekends. And even though there are FM programs doing high speed rotations like JPS, they still get limited ED time. They get a better ICU experience and inpatient medicine experience, but that still does not make them anywhere near the minimum standard for EM accreditation. And those programs are the best case scenario.

What separates EM docs from FM docs is the routine ability to confidently manage that really sick one in 6 persons who is needing to go to the ICU, the OR, the cath lab, etc...etc.. The stuff we do is not rocket science, but it takes a different approach that takes a really long time to perfect and be timely with.

My major thesis in my first post was that FM docs are not going to be working long in academic ED settings, and that eventually they will be pushed to the side in other settings as well. It's just a fact. Of course there are good FM ED docs, and rightly so as they created the profession. But you don't see EM docs trying to run a family medicine clinic!!

SJ

 

[halodoctor]

My board scores are more than a standard deviation above the national average for the year I took the exam (Step I that is, which I assume you are referring). We have an incoming intern for next year's class with boards just under 250. Not everyone that does FM is saddled with low board scores. That's a dangerous assumption.

i have seen scores of 270 going into fm. i respect your opinion tn family md because through these posts you have laid out the truth, but the point i made was not that there are scores that are up there. i was merely stating that the average is far lower.

again, it's just a number reference. personally i feel like i'm much smarter than the score i received and also think that i can take care of patients about a hundred times better than others in my class who received scores above 240. so i wasn't trying to equate the board score to the level of care. again, something people missed when i made the step 1 comment was the fact that everyone greeted this resident with smiles even though in working with her i found out that she has a very poor learning curve. and that is probably more respectable than any board score.

 

[halodoctor]

Well, you certainly dug yourself a deeper hole. 🙄

nice picture kent, but how so?

 

[Tn Family MD]

After 6 months in an EM residency, most residents have completed 3 months of ED and 3 months of critical care....trauma/MICU/SICU/CVICU/etc...etc..

And I hate to burst your bubble, but admission rates at major academic medical centers range from 25-35% on average, meaning as many as every 3rd patient requires admission. Of the admissions, more than half go to the ICU. So every 6th patient really needs someone competent in critical care and knowledgable about critical care medicine.




SJ

I know you don't really care, but my first four months of residency included a month of Trauma at our level I trauma center, a month of Critical Care Medicine, and a month of In-patient where-in we managed our ICU transfers for the first 18-24 hours post transfer, so in fact we do get a lot of the exposure you think we are missing.

And having just finished an EM month last month, I can tell you beyond all shadow of a doubt that no where near 25-35% of our ED evals get admitted and no where near 1 in 6 ends up in the unit. I don't know where you pulled those numbers from, but here at our hospital my real world experience is in stark contrast to what you suggest.

And, again, I know you don't care but I will have at least another three months of critical care (ICU) rotations before I graduate. I think you have had a very skewed experience of Family Medicine in general when you were in med school. Maybe your exposure to some very weak FM programs has tainted your experience, but there are plenty of fantastic programs out there where you get exceptional training whether you believe that to be so or not.

 

[deleted87716]

nice picture kent, but how so?

I think TN Family MD has done a good job clarifying things.

 

[iatrosB]

i have seen scores of 270 going into fm. i respect your opinion tn family md because through these posts you have laid out the truth, but the point i made was not that there are scores that are up there. i was merely stating that the average is far lower.

again, it's just a number reference. personally i feel like i'm much smarter than the score i received and also think that i can take care of patients about a hundred times better than others in my class who received scores above 240. so i wasn't trying to equate the board score to the level of care. again, something people missed when i made the step 1 comment was the fact that everyone greeted this resident with smiles even though in working with her i found out that she has a very poor learning curve. and that is probably more respectable than any board score.

It wasn't just the board scores comments, everyone knows the average score is lower for FM. It's the comments like:

"...sometimes i get so frustrated working w/ family residents because on the average they are the less competent ones."

that are just rediculous. If kent has to explain the picture, you wouldn't get it anyway.

 

[FoughtFyr]

http://www.aafp.org/fellowships/other.html

Go to this website and scroll down. I believe there are 5 1 year approved fellowhips in EM off of FM. Granted, this may not give u the same status as a board certified EM doc but maybe a last resort? Some hospitals would prob. give u a second look over a regular FP doc.

Hope this helps.

BMW-

I wasn't going to touch this as those who know me IRL think I have an "anti-FP" bias. I do, but it comes as the result of attending a medical school where FP was "forced" on each student, and the political agenda of the AAFP ran rampant. I was often told not to go into EM but rather FP. When I started school those giving this counsel said they were certain the "practice pathway" would be reopened. When that lawsuit (finally) settled, they advised an FP EM fellowship. To quote Col. Potter - "HORSEPUCKY!"

There is no "ER Certicfication" for FPs that is accepted by the ABEM. (And given that you are a newbie you should know that some people here might get offended at the term "ER", it is an "Emergency Department" with many rooms. The specialty is "Emergency Medicine" or "EM" and we are "Emergency Physicians" or "EP"s). While the AAFP does offer fellowships in EM, these do not lead to board certification by ABEM. There is currently no pathway, other than an EM residency, to become board certified in EM.

Does board certification matter? Yes and no. Certainly there are academic papers that suggest the residency trained EP is less likely to be sued than the non-EM residency trained EP. And this has been noticed by med-mal carriers. Many have begun refusing to cover non BE/BC EPs. But, for now, the demand for BE/BC EPs is greater than the supply. So yes, you can find work as an FP in smaller community facilities. It would be nearly unheard of now for an FP to be hired into academic or tertiary centers (but some tenured physicians might still remain).

What you should realize is that this career path (an FP practicing EM) might be severely limited. First, should you be sued and lose, or even have the appearance of liability, it is doubtful your med-mal carrier will allow to continue to practice EM (of course, for an FP the same is true of OB). Even if you don't suffer a suit, at any time, the hospital you are affiliated with can switch EM groups. These buy-outs are not infrequent, and it is unlikely FPs would be kept on. Lastly, it is not only your med-mal carrier, but that of the hospital where you work that might "squeeze" you out. For example, where I trained one of the hospitals is "home" to the FP residency. Their level-II trauma canter, 40K visit ED was staffed with a mix of FPs and EM-trained EPs. The residents also rotated through. After an unsuccessful lawsuit, the hospital's med-mal carrier threatened to drop coverage if the ED was not converted to all BE/BC EPs. An EM corporate group was in place within a month. All of the residency trained EPs were kept, and all of the FPs were let go. Some had 10+ years in the department and were quite skilled. When I left, the hospital was still negoiating to allow the FP residents to continue their EM rotations.

Basically, you should realize that EM is a specialty, just like surgery, cardiology, rheumatology, etc. And while an FP knows something of the conditions we evaluate and treat, their methodology and focus are completely different from ours. And, given the AAFP "practice pathway" lawsuit, and the sideline view of the onoing struggles between OB and FP, it is unlikely that FPs will find a wellspring of support for maintaining a presence in EM. Besides, do you really think that with 1 or 2 months of ED training you are equivalent to an EP? To suggest so is kind of insulting to those of us in EM residencies. Remember, if you are sued while working in the ED, you will be held to the standards and practices of emergnecy medicine, not to those of family practice. You'd be surprised at how different those two approaches to medicine are...

Bottom line, if you want to do EM, do EM. If you want to do FP, do FP.

Just my $0.02 worth (actual cash value $0.005)

- H

 

[sophiejane]

I wasn't going to touch this as those who know me IRL think I have an "anti-FP" bias. I do, but it comes as the result of attending a medical school where FP was "forced" on each student, and the political agenda of the AAFP ran rampant. I was often told not to go into EM but rather FP. When I started school those giving this counsel said they were certain the "practice pathway" would be reopened. When that lawsuit (finally) settled, they advised an FP EM fellowship. To quote Col. Potter - "HORSEPUCKY!"

Isn't it time to let go of some of the baggage you are dragging around from medical school? To base a broad "anti-FP" bias in your current professional life (I'm just assuming your are a professional and not a resident, but it holds either way) on the fact that your school pushed it is pretty ridiculous. Kind of like the 30 year old who won't clean his apartment because he had to do too many chores as a teenager.

Also, since you took the time to educate us on the proper parlance for Emergency Physicians and the arena in which they practice, perhaps you'd return the favor by addressing our specialty as FM for Family Medicine. Family Physicians are FPs.

 

[FoughtFyr]

Isn't it time to let go of some of the baggage you are dragging around from medical school? To base a broad "anti-FP" bias in your current professional life (I'm just assuming your are a professional and not a resident, but it holds either way) on the fact that your school pushed it is pretty ridiculous. Kind of like the 30 year old who won't clean his apartment because he had to do too many chores as a teenager.

Also, since you took the time to educate us on the proper parlance for Emergency Physicians and the arena in which they practice, perhaps you'd return the favor by addressing our specialty as FM for Family Medicine. Family Physicians are FPs.

I have let it go. I see an FP for my family's medical needs. I see FM (thank you for the correction) as a very valid and necessary medical specialty. I just bristle at those who would slight your profession by suggesting that it is something it is not - namely emergency medicine. The answer to this is simple, you can't remain a pleuripotent stem cell forever. Eventually you need to make a choice of a medical career. Now, if that choice is to practice Family Medicine, wonderful! We need more dedicated providers in this arena. Likewise if your choice is to practice emergency medicine, great, we need help here too. But don't insult either profession by sugesting that they are interchangable. They aren't. FPs who do an EM fellowship have wasted a year (or two) of their lives trying to become something they aren't. Similarly, a EP who tries to fashion some training together in order to "hang out an FM shingle" is deluded. They are very different specialties with some overlap (but hey, both overlap with just about every area of medicine) and their practitioners deserve the respect afforded to any other provider.

I guess I should re-state my bias as an "anti militant FM bias - specifically against those who, for political purposes, attempt to persuade niave medical students into believing that FM is something other then the much needed primary care specialty it is". Is that better?

- H

 

[iatrosB]

I have let it go. I see an FP for my family's medical needs. I see FM (thank you for the correction) as a very valid and necessary medical specialty. I just bristle at those who would slight your profession by suggesting that it is something it is not - namely emergency medicine. The answer to this is simple, you can't remain a pleuripotent stem cell forever. Eventually you need to make a choice of a medical career. Now, if that choice is to practice Family Medicine, wonderful! We need more dedicated providers in this arena. Likewise if your choice is to practice emergency medicine, great, we need help here too. But don't insult either profession by sugesting that they are interchangable. They aren't. FPs who do an EM fellowship have wasted a year (or two) of their lives trying to become something they aren't. Similarly, a EP who tries to fashion some training together in order to "hang out an FM shingle" is deluded. They are very different specialties with some overlap (but hey, both overlap with just about every area of medicine) and their practitioners deserve the respect afforded to any other provider.

I guess I should re-state my bias as an "anti militant FM bias - specifically against those who, for political purposes, attempt to persuade niave medical students into believing that FM is something other then the much needed primary care specialty it is". Is that better?

- H

I'd say that is pretty good bomb de-fusal. 👍

 

[deleted87716]

Bottom line, if you want to do EM, do EM. If you want to do FP, do FP.

In this day and age, I tend to agree with you.

 

[iatrosB]

Bottom line, if you want to do EM, do EM. If you want to do FP, do FP.

- H

Is it safe to assume that both FM and EM are adequate for "urgent care"?

 

[sophiejane]

I guess I should re-state my bias as an "anti militant FM bias - specifically against those who, for political purposes, attempt to persuade niave medical students into believing that FM is something other then the much needed primary care specialty it is". Is that better?

- H

Yes, thank you. 🙂

And, to clarify, in no way do I think FM and EM are interchangeable. I just think that until EM docs are willing to practice in rural areas, FM will have to continue to fill that need, with varying degrees of competence. (See my above post, about the rural hospital who has been trying to get a full time EM boarded physician for over a year with no luck...) I'd like nothing more than to see EM boarded docs in every ED in the country. I just don't see that happening anytime soon, particularly since the majority of the US population live in rural areas.

It would be interesting to see how many of the bazillion (a slight exaggeration, but only slight 😉 ) US grads who just matched EM plan to work in a rural or underserved area. I'd venture that the majority chose EM because it is the currently hot "lifestyle" specialty, and I seriously doubt that many of those new grads consider having cows as neighbors to be the lifestyle they are looking for.

Give me cows anyday. 😉

 

[deleted87716]

Is it safe to assume that both FM and EM are adequate for "urgent care"?

Urgent care is just primary care without an appointment. 😉

All kidding aside, most of the patients that I've picked up who were previously "followed" by an urgent care center for their chronic medical problems were pretty poorly managed. Urgent care centers have their place, but they're not a true "medical home" any more than the ED is.

 

[deleted77919]

I just don't see that happening anytime soon, particularly since the majority of the US population live in rural areas.

I hate to be nit-picky, but this isn't true.

58% of Americans live in areas of 200,000+
10% of Americans live in areas of 50,000-200,000

http://www.fhwa.dot.gov/planning/census/cps2k.htm

 

[iatrosB]

I hate to be nit-picky, but this isn't true.

I doubt that. 🙄

 

[deleted109597]

And having just finished an EM month last month, I can tell you beyond all shadow of a doubt that no where near 25-35% of our ED evals get admitted and no where near 1 in 6 ends up in the unit. I don't know where you pulled those numbers from, but here at our hospital my real world experience is in stark contrast to what you suggest.

And all hospitals are different. However, coming from someone who just went through a cycle of applying to EM, I can tell you that his numbers are closer to what most Level I places out there are getting. The residencies furnish these numbers because they want to show that they really are getting sick people, and not just running a fast track.

One hospital had a 30% ICU admission (of all comers, not just of admits). That place had close to 50% admissions, but tertiary centers end up getting the really sick, because people don't want to wait 8 hours for their flu symptoms.

Your anecdotal real world experience is in stark contrast to what many places are.

 

[awdc]

And all hospitals are different. However, coming from someone who just went through a cycle of applying to EM, I can tell you that his numbers are closer to what most Level I places out there are getting. The residencies furnish these numbers because they want to show that they really are getting sick people, and not just running a fast track.

One hospital had a 30% ICU admission (of all comers, not just of admits). That place had close to 50% admissions, but tertiary centers end up getting the really sick, because people don't want to wait 8 hours for their flu symptoms.

Your anecdotal real world experience is in stark contrast to what many places are.

I agree. On one of my EM rotations (where I also interviewed) at a level II trauma community hospital in a very large city, they had an admission rate of 45% with critical care admissions around 20-30% depending on whether these admissions actually went to a critical care unit. The place was insanely busy where two to a bay is the norm 24/7. It wasn't uncommon for a line of incoming patients on gurneys to form from triage out to the ambulance bay. Heck, it made some level 1 trauma centers look pretty cushy. Thank goodness they're doubling the size of the ED.

 

[razorback58]

Why is everyone so against FM? It most managed care situations they are the "gate keeper". In most cases you can't see your specialist without a referral. I have found this true for neuro, cardio, ENT, nephro and GI.

How do you think most people get to your office?

The reason why most people go to the ED is because they cannot get into to see their FM doctor because they are too busy and there is not enough of them.

FP does EM in the rural areas because we don't have enough of them. I think we do a good job on the non-critical side to free up time for trauma for ED docs. Actually the money is quite good for the ED doc's practicing in smaller communities. Heck, I have seem derm people and anesthesia people doing moonlighting in the ED in rural areas.

 

[Seaglass]

If you would like to see what the admission rate is at hospitals that host EM residencies you can get that info at EMRAMatch.org. We also have a large comminut hospital in our city with a comparable admission rate.

With reagrd to the previous post - I don't think anyone is against FM - we just don't buy the idea that FM Residency gives you the same or equal qualifications to staff an ED as EM residency does.

 

[halodoctor]

http://kleinmatic.typepad.com/photos/lula_0704/foot_in_mouth.jpg

 

[deleted87716]

http://kleinmatic.typepad.com/photos/lula_0704/foot_in_mouth.jpg

Cute. I like that one, too. 😉

 

[deleted87716]

I don't think anyone is against FM - we just don't buy the idea that FM Residency gives you the same or equal qualifications to staff an ED as EM residency does.

I'm not sure anyone has disputed that.

 

[halodoctor]

thanks kent, i wish i could be as judicious with my words as foughtfyr has been in expressing his true feelings.

i apologize for the disturbing stereotype. as i read over the post, it just sounded wrong. i guess it would be best to say that my limited experience with predominantly img fm residents has given me a false picture that i have taken to be reality.

in any case, a picture is worth a thousand words... thanks to everyone for keeping this conversation alive and insightful.

 

[sophiejane]

thanks kent, i wish i could be as judicious with my words as foughtfyr has been in expressing his true feelings.

i apologize for the disturbing stereotype. as i read over the post, it just sounded wrong. i guess it would be best to say that my limited experience with predominantly img fm residents has given me a false picture that i have taken to be reality.

in any case, a picture is worth a thousand words... thanks to everyone for keeping this conversation alive and insightful.

That's why I think some of us have tried to be a bit more gentle with our criticism of your comments. 😉

Do you know how tricky it can be to measure an AFI, for example? I've seen 2nd year OBGyn residents fumble with the sono. And remember, that FM resident has had only a fraction of the OB time the OBGyn resident has had--most are not trained in ultrasonography.

That's just an example. You will see as you move on how it's not all as easy as it looks, and you will meet some of the smartest folks with excellent grades and test scores in the FM world. I'm talking PhD and AOA smart. Could they have been a cardiothoracic surgeon? Heck yeah. But not only that, they can actually hold a conversation and their patients love them rather than tolerate them with a wince.

I've seen on the interview trail that the VAST majority of US seniors choosing FM are CHOOSING it from the heart--it really is what they want to do, and their credentials or their reimbursement has nothing to do with it. (However, you will also learn that not every cardiologist makes $500K/year--some make much less--and not every FP makes $100K--some make much more).

Good luck in your journey.

 

[sophiejane]

I hate to be nit-picky, but this isn't true.

58% of Americans live in areas of 200,000+
10% of Americans live in areas of 50,000-200,000

http://www.fhwa.dot.gov/planning/census/cps2k.htm

You may be right. I have no idea how people in rural areas are counted by the census, but my guess is they are included by their post office or zip code. That could put you quite a bit out of town, so they are not all "in" areas of those numbers. I just remember hearing that once--that most Americans do not live in urban areas.

The more important issue for me is the physician: patient ratio and the number underserved counties that make up a state. I know the vast majority of my state is underserved.

 

[Apollyon]

I read something once that I cannot find again that 80% of the population of North America lives within a 500 mile radius of New York City. I wish I could find it again.

 

[FoughtFyr]

I'm not sure anyone has disputed that.

Actually they have Kent. The AAPS (an "alternative" EM "board" if you believe their BS) accepts the FM based EM Fellowships and purports to "board certify" their graduates. The AAPS is suing the New York Department of Health to allow these physicians to advertise as "board certified" in EM. They have already won that right in Florida.

Imagine if the roles were reversed. Imagine if, in inner cities, owing to the lack of primary care access, groups of emergency physicians opened up small "family medicine clinics" in the back of their EDs to see patients from the community as primary care physicians. They argue that these patients will merely end up in the ED anyway and that their floor months during residency equips them to see these patients in this outpatient longitudinal setting. These physicians state that they are "close enough" to an FP to "make do" for these otherwise unserved patients. Imagine if medical students, bright and eager to enter family medicine, were being disauded from that vocation to enter EM with the promise that these clinics "were essentially the same" as "regular" FM. Then, the ABEM hobbles together a one year fellowship in outpatient medicine and a group demands that graduates of these fellowship be allowed to advertise as "board certified family practitioners".

You'd probably be a bit salty about it too...

- H

 

[sophiejane]

FF, it sounds like you went to a particularly militant-FM type school. I don't think that's the norm. In fact, at my school, which is ranked nationally for primary care and makes this huge deal out of preparing us for primary care, they still didn't put that much pressure on us to do FM.

You make some good points, but the thing is, I'd be surprised if there were large numbers of students being pressured to choose FM. I've heard many stories of the opposite, where students are actively discouraged from FM, but yours is the only one I've heard of that has the reverse situation.

 

[iatrosB]

Actually they have Kent. The AAPS (an "alternative" EM "board" if you believe their BS) accepts the FM based EM Fellowships and purports to "board certify" their graduates. The AAPS is suing the New York Department of Health to allow these physicians to advertise as "board certified" in EM. They have already won that right in Florida.


- H

I'm pretty sure he was just talking about no one disputing that in this thread, not in general.