FP in the ER

[deleted6669]

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Last time I checked, midlevels were staffing EDs as well. Which would you rather, a PA, NP, or a non-ABEM boarded FP?

I know which one I'd pick if I was the patient. And it's not the midlevel.

and that would be the wrong choice.....a midlevel with lots of experience in em runs laps around any physician in the e.d. except for a residency trained,board certified em physician.
I precept 2nd and 3rd yr fm residents in the e.d.
I also orient the f.m. physicians who do shifts in our e.d.
our em pa group is made up of former paramedics all with > 10 yrs experience ( range is 10-30 yrs) exclusively working as pa's in em. we do all of our cme in em. we attend all of the em dept mtgs, m+m, grand rounds, etc. we all get certed in acls/atls/pals/fccs/difficult airway course. in addition to staffing a busy trauma ctr we also staff a level 4 e.d. as the only providers.
an fm physician with less than a yr of exposure(and that's being generous) to em during medschool and residency doesn't even come close to the em knowledge base of a pa who has done nothing else for yrs......
if your arguement is new grad pa vs new grad fm physician I can see your point, however the experienced em pa vs almost any fm physician is a totally different story.....

 

[Sinnman]

Last time I checked, midlevels were staffing EDs as well. Which would you rather, a PA, NP, or a non-ABEM boarded FP?

I know which one I'd pick if I was the patient. And it's not the midlevel.

Agreed.😉

 

[iatrosB]

and that would be the wrong choice.....a midlevel with lots of experience in em runs laps around any physician in the e.d. except for a residency trained,board certified em physician.
I precept 2nd and 3rd yr fm residents in the e.d.
I also orient the f.m. physicians who do shifts in our e.d.
our em pa group is made up of former paramedics all with > 10 yrs experience ( range is 10-30 yrs) exclusively working as pa's in em. we do all of our cme in em. we attend all of the em dept mtgs, m+m, grand rounds, etc. we all get certed in acls/atls/pals/fccs/difficult airway course. in addition to staffing a busy trauma ctr we also staff a level 4 e.d. as the only providers.
an fm physician with less than a yr of exposure(and that's being generous) to em during medschool and residency doesn't even come close to the em knowledge base of a pa who has done nothing else for yrs......
if your arguement is new grad pa vs new grad fm physician I can see your point, however the experienced em pa vs almost any fm physician is a totally different story.....

I don't think anyone will argue with you there (although I'm sure I'll be proven wrong). You always have to compare apples to apples.

 

[polygonal]

and that would be the wrong choice.....a midlevel with lots of experience in em runs laps around any physician in the e.d. except for a residency trained,board certified em physician.
I precept 2nd and 3rd yr fm residents in the e.d.
I also orient the f.m. physicians who do shifts in our e.d.
our em pa group is made up of former paramedics all with > 10 yrs experience ( range is 10-30 yrs) exclusively working as pa's in em. we do all of our cme in em. we attend all of the em dept mtgs, m+m, grand rounds, etc. we all get certed in acls/atls/pals/fccs/difficult airway course. in addition to staffing a busy trauma ctr we also staff a level 4 e.d. as the only providers.
an fm physician with less than a yr of exposure(and that's being generous) to em during medschool and residency doesn't even come close to the em knowledge base of a pa who has done nothing else for yrs......
if your arguement is new grad pa vs new grad fm physician I can see your point, however the experienced em pa vs almost any fm physician is a totally different story.....

I will preface this with I like PAs. I think PAs are an asset to healthcare. Although I've certainly encountered exceptions, I feel that the PA profession is well centered and not putting politics over patient care (read: NPs).

Having said that, your argument is an apples to oranges comparison. You are comparing a seasoned EM PA to a new grad FP. Different animals. The correct comparison should be a seasoned PA to a seasoned FP. Under that context, the FP would clearly come out ahead. Your average graduating medical student will outperform your average PA given similar post-graduate training. There IS (obviously) a difference. Arguing this point is foolish and it really makes me wonder why these arguments even exist.

 

[deleted6669]

I will preface this with I like PAs. I think PAs are an asset to healthcare. Although I've certainly encountered exceptions, I feel that the PA profession is well centered and not putting politics over patient care (read: NPs).

Having said that, your argument is an apples to oranges comparison. You are comparing a seasoned EM PA to a new grad FP. Different animals. The correct comparison should be a seasoned PA to a seasoned FP. Under that context, the FP would clearly come out ahead. Your average graduating medical student will outperform your average PA given similar post-graduate training. There IS (obviously) a difference. Arguing this point is foolish and it really makes me wonder why these arguments even exist.

so you believe that an fp doc 5 yrs out of residency pulled into the e.d. out of their primary care clinic to work a shift in the e.d. would outperform an em pa 5 yrs out of school who has done nothing but em for 5 yrs?
if that is your arguement it is certainly flawed. many clinic fm docs don't do the vast majority of em procedures that I do every day. I taught a moonlighting fm doc how to do a digital block last week.....
now if your arguement is comparing an fm doc who went to work for an e.d. right out of residency and never works in the clinic compared to an em pa with similar time in the e.d. than that is a more valid arguement.
keep in mind that some em pa's( say me) concentrated heavily in em during school so (in my not so humble opinion) ran circles around most medschool grads who had not yet done a residency. in my 54 week clinical yr in addition to all the standard rotations in primary care specialties I also did trauma surgery, peds em, community hospital em and trauma ctr em for a total of 27 weeks. that's half of my clinical training in em in pa school before my postgrad masters in em and not counting 10 yrs of prior ems experience.....what does a typical medstudent heading for fm get in school for em experience?
1 six week rotation? and even if they do an fm residency they do an additional 3 months in the e.d......so 4-5 months of em total for a typical fm residency grad....I had more than that as a pa student.....
as an aside I have worked with many fm docs who became board certified via the old practice track prior to 1986 as well as a few docs who have done the 1 yr em fellowships for fm docs and they are all excellent em physicians. I think in a perfect world fm docs could do a 1 yr fellowship and sit for the abem exam and em docs could do a 1 yr fellowship to sit for the fm exam. there really is quite a bit of overlap. I'm surprised that the new md fm/em residencies didn't fill this yr. when I think about going back to medschool it always comes down to a desire to do rural fm with ed coverage and high risk ob with sections so a really intense fm residency( say ventura/contra costa/natividad) or a dual fm/em residency would fit the bill.

 

[Static Line]

so you believe that an fp doc 5 yrs out of residency pulled into the e.d. out of their primary care clinic to work a shift in the e.d. would outperform an em pa 5 yrs out of school who has done nothing but em for 5 yrs?
if that is your arguement it is certainly flawed. many clinic fm docs don't do the vast majority of em procedures that I do every day. I taught a moonlighting fm doc how to do a digital block last week.....
now if your arguement is comparing an fm doc who went to work for an e.d. right out of residency and never works in the clinic compared to an em pa with similar time in the e.d. than that is a more valid arguement.
keep in mind that some em pa's( say me) concentrated heavily in em during school so (in my not so humble opinion) ran circles around most medschool grads who had not yet done a residency. in my 54 week clinical yr in addition to all the standard rotations in primary care specialties I also did trauma surgery, peds em, community hospital em and trauma ctr em for a total of 27 weeks. that's half of my clinical training in em in pa school before my postgrad masters in em and not counting 10 yrs of prior ems experience.....what does a typical medstudent heading for fm get in school for em experience?
1 six week rotation? and even if they do an fm residency they do an additional 3 months in the e.d......so 4-5 months of em total for a typical fm residency grad....I had more than that as a pa student.....
as an aside I have worked with many fm docs who became board certified via the old practice track prior to 1986 as well as a few docs who have done the 1 yr em fellowships for fm docs and they are all excellent em physicians. I think in a perfect world fm docs could do a 1 yr fellowship and sit for the abem exam and em docs could do a 1 yr fellowship to sit for the fm exam. there really is quite a bit of overlap. I'm surprised that the new md fm/em residencies didn't fill this yr. when I think about going back to medschool it always comes down to a desire to do rural fm with ed coverage and high risk ob with sections so a really intense fm residency( say ventura/contra costa/natividad) or a dual fm/em residency would fit the bill.

It all boils down to training. As a former 10 year paramedic myself who is wants to go FM over ED I can see both angles. FM people need to realize that nobody is questioning your intelligence. To make it through med school today you can't be a total idiot (though I have seen many of them make it). What is being questioned is your level of training. Before I left for med school there was one ED doc who wasn't that squared away. He was extremely cautious at the wrong times. He was very hesitant to let the paramedics do anything when they called on the radio requesting additional orders. He was very slow in the ED. He still couldn't run a code without looking at his book after many years. Everyone made fun of him and he was the brunt of many jokes. This was an ED that couldn't afford that as well over a 100k pts every year were seen here. He was a very nice guy and I liked him a lot. The problem was he was only FM trained and you could tell a huge difference between him and the other ER docs. I just found out he was only FM trained last month which completely answered many questions for me. I always thought he was an ER doc. By the time I left for school he was getting up to speed but it took a long, long time, and it happened at the expense of patients. He was grandfathered in to the ED and so they just left him but now they only take BE/BC ED docs into my old ER.

There was a good reason that the ER residencies and ED trained docs came into existence. The old way didn't work as well any more. I have no doubt that any FM trained person could make it in the ER if properly trained.You all (we all) are smart enough. However, the FM residency today doesn't supply that needed training so by virtue of training the typical FM trained doc today wouldn't make it in most ER's. In a rural setting what else are we gonna do. But believe me, if there were enough ED docs to go around a FM doc would be hard pressed to find a job in the rural setting as well.

And by the way, many of the PA's at my ED who were trained in emergency care I would prefer over that doc I am talking about. They are good.....

Peace

 

[deleted6669]

thanks- I don't think an fm doc right out of residency should work in the ed unsupervised either but I can see it after an intensive 1 yr fellowship that includes lots of precepted time in the icu, peds e.d., anesthesia service, and of course the ed itself.
the fm docs who work at my primary job(trauma ctr) are all very good and were among the 1st wave of docs to work full time in the ed after residency. many of them have taught at em residency porograms. they are all grandfathered into em board certification. that being said for the last 10 yrs or so they only have hired residency trained/boarded em docs. after the old timers retire in a few yrs it will be all residency trained em folks.
another facility I work at uses em pa's 24/7 with a single fm doc on day shift only. for the most part these are also guys who have done only em since residency but are too young to be grandfathered em. a few have done the "alternate " bcem certification. they are all very good. we also have moonlighting fm residents and fm docs from the community who fill in the holes in the fm day shift schedule. they have very little em exposure and for the most part are all fairly scary/dangerous in that setting in addition to not being able to keep up with flow. I worked with 1 of them last week and in the same 8 hr period seeing pts of similar acuity from the same rack I saw 35 pts to her 9. there is a bit of justice though because the full time pa's there make more/hr than moonlighting residents or community fm docs. the full time fm guys make 10/hr more than the pa's.

 

[polygonal]

so you believe that an fp doc 5 yrs out of residency pulled into the e.d. out of their primary care clinic to work a shift in the e.d. would outperform an em pa 5 yrs out of school who has done nothing but em for 5 yrs?
if that is your arguement it is certainly flawed.

That is not what I'm saying. You are comparing a seasoned EM PA to a wet-behind-the-ears FP doc. I'm saying the average FP trained doc with the equivalent EM experience as an average PA will be clinically superior. In my experience it's been quite dramatic, maybe not in the routine stuff but in the more unusual things. This should not be a shock. There is a difference between PA school and medical school (yet alone the FP residency).

You are also not making a valid comparison between you with X number of years of experience prior to PA school and a medical student with none. What do think the outcome would be between a PA with 10 years of EMS experience and a doc with 10 years of experience? BTW, I have over 10 years of EMS experience (very similar to yours) and I really did not think that made a huge difference in my performance by the end of medical school. The EMS experience is great but it experience curve flattens out really fast.

I'm not trying to get into a urinating (don't want to offend) contest with you. I just like consistency.😉

 

[deleted87716]

Just to keep the thread on track, the original post didn't have anything to do with PAs.

 

[deleted6669]

Just to keep the thread on track, the original post didn't have anything to do with PAs.

agreed- several posters felt the need to bring in a midlevel angle so I felt compelled to respond. by all means let's get back to the original topic.

 

[deleted6669]

That is not what I'm saying. You are comparing a seasoned EM PA to a wet-behind-the-ears FP doc. I'm saying the average FP trained doc with the equivalent EM experience as an average PA will be clinically superior. In my experience it's been quite dramatic, maybe not in the routine stuff but in the more unusual things. This should not be a shock. There is a difference between PA school and medical school (yet alone the FP residency).

You are also not making a valid comparison between you with X number of years of experience prior to PA school and a medical student with none. What do think the outcome would be between a PA with 10 years of EMS experience and a doc with 10 years of experience? BTW, I have over 10 years of EMS experience (very similar to yours) and I really did not think that made a huge difference in my performance by the end of medical school. The EMS experience is great but it experience curve flattens out really fast.

I'm not trying to get into a urinating (don't want to offend) contest with you. I just like consistency.😉

no offense intended from this side either. I concede you make several valid arguements. peace-e

 

[ajce9]

I have followed this discussion on many other posts. some of them get very heated.

I don't mean for my comment to be taken wrong.

The truth is that PAs are taking FPs jobs.

If there was not PA to train in the ER to do those ER procedures, then an FP may want to do it. In fact because of the FPs Medical school background they would be able to learn the material much faster and with far less INITIAL supervision.

I don't mean to say that the PA will not eventually learn it but why should be use a PA when there a MDs around willing to do it and why should we take valuable time away from training a resident MD and give it to a PA?

 

[urgewrx]

in my 54 week clinical yr ...

I got short changed! My year only has 52 weeks 😡

 

[Static Line]

I have followed this discussion on many other posts. some of them get very heated.

I don't mean for my comment to be taken wrong.

The truth is that PAs are taking FPs jobs.

If there was not PA to train in the ER to do those ER procedures, then an FP may want to do it. In fact because of the FPs Medical school background they would be able to learn the material much faster and with far less INITIAL supervision.

I don't mean to say that the PA will not eventually learn it but why should be use a PA when there a MDs around willing to do it and why should we take valuable time away from training a resident MD and give it to a PA?

The PA's where I came from had their scope of practice limited. They could see some of the chronicly ill or minorly injured patients who need xrays or sutures and labs etc...but who were not critical. The acutely ill very sick were seen by the doc and so were the good traumas. It is a good system and well within the pa's scope of practice. How do you think a FM physician would deal with an ER doc looking over their shoulder to make sure they didn't take a patient that didn't belong to them? Even if the FM could handle it. What would you do as a FM doc if that happened to you? Another physician saying you can't handle something you know darn good and well you can. There would be enormous power struggle. It wouldn't work. That doesn't happen with pa's because they are aware of their scope.

There are plenty of meaningful places for FM docs to practice. It's just not the way of the world anymore for that place to be an ER.

 

[ajce9]

The PA's where I came from had their scope of practice limited. They could see some of the chronicly ill or minorly injured patients who need xrays or sutures and labs etc...but who were not critical. The acutely ill very sick were seen by the doc and so were the good traumas. It is a good system and well within the pa's scope of practice. How do you think a FM physician would deal with an ER doc looking over their shoulder to make sure they didn't take a patient that didn't belong to them? Even if the FM could handle it. What would you do as a FM doc if that happened to you? Another physician saying you can't handle something you know darn good and well you can. There would be enormous power struggle. It wouldn't work. That doesn't happen with pa's because they are aware of their scope.

There are plenty of meaningful places for FM docs to practice. It's just not the way of the world anymore for that place to be an ER.

My example was about the ER because that what people had posted about.
But my main point is that if we are going to train someone in medicine, all training should first go to the MDs not their assistants.

We know the education of a physician is better. We also know that physicians have to do a residency. If I'm in a residency program and I have PAs rotating with me or a PA is rotating with a GI or Cardiology attending that I happen to be rotating with, then I will lose valuable time with that specialist during my training. The PA gets that time. But I'm the MD, I'm the one in residency and I'm the one that will be expected to train a PA one day or supervise a PA one day OR simply know the material so I can treat my patients.

I don't think it is right that my training time is being given away to someone who may be my assistant at some time.

Physicians need to be given 1st priority at all times in their training. They are the ones that will practice independently.

I understand the financial incentive behind hiring a PA but the fact is that if an MD is given the proper training post Medical school they will do better than PAs. Not because PAs are ignorant or don't know anything, they do, but because the MDs are better educated as doctors.

 

[sophiejane]

There are plenty of meaningful places for FM docs to practice. It's just not the way of the world anymore for that place to be an ER.

Would that this were true...

The way of the world in many EDs still appears to be FM or nothing, until you guys either choose to practice in those un-sexy places, or train so many EM docs that they don't have a choice.

Meantime, pass me the T-sheet, I'm going in...

(and sounding like a broken record because NOBODY from the EM camp wants to respond to what I'm saying. Over. and over. and over.)

 

[sophiejane]

I got short changed! My year only has 52 weeks 😡

It's a PA thing. They get an extra couple of weeks to catch up every year. 😉 <<SJ ducks and covers>>>

 

[deleted109597]

Would that this were true...

The way of the world in many EDs still appears to be FM or nothing, until you guys either choose to practice in those un-sexy places, or train so many EM docs that they don't have a choice.

Meantime, pass me the T-sheet, I'm going in...

(and sounding like a broken record because NOBODY from the EM camp wants to respond to what I'm saying. Over. and over. and over.)

Hey, we aren't saying that you can't work there. We are saying that the training isn't equivalent. I would rather FM work there than, say, peds, or IM, or surgery, simply because you have a broader range of experience in residency. Slowly, as more grads keep popping out (EM has a big number of spots now), more and more spots that used to be open to FPs won't be there anymore. That's all we are saying. That, and you shouldn't fight to be considered equivalent.

 

[FoughtFyr]

Would that this were true...

The way of the world in many EDs still appears to be FM or nothing, until you guys either choose to practice in those un-sexy places, or train so many EM docs that they don't have a choice.

Meantime, pass me the T-sheet, I'm going in...

(and sounding like a broken record because NOBODY from the EM camp wants to respond to what I'm saying. Over. and over. and over.)

O.k. I'll respond (and I already have on the similar thread in the EM forum). You are correct, there are not enough BC/BE EPs to staff all of the rural EDs. But where does that logic end? Now we know that "time is muscle" in an MI and the latest data suggest that PCTA is a lower risk intervention than lytics. Should we allow FPs to do a 1-2 year cards fellowship and perform caths at rural hospitals? How about interventional radiology? I mean bad PEs, pelvic/splenic bleeds aren't usually going to be able to be safely transferred many miles away. How about training the FP to do these procedures to help eliminate the health disparities seen in the "un-sexy" areas of the country?

Yes, I am being sarcastic...

I guess my problem is that the public simply doesn't know who staffs their local EDs. As a resident, I've recieved lots of patients who confidently describe the care they've recieved from Dr. X at the Anytown General Hospital ED. They've raved about the care Dr. X gave them. Not only do I have to choke down the fact that Dr. X completely missed the diagnosis, but I have to chuckle to myself knowing full well Dr. X is a heme/onc fellow who is moonlighting. My problem is not that FPs staff these EDs but rather that the public doesn't know who is treating them. (My similar pet peeve in our ED is the "off service" resident who gives report to admitting services stating "I'm Dr. Y, an emergency department resident. No, you aren't. You are Dr. Y, an IM resident assigned to the ED, but I digress)

I suppose the ultimate answer would be to change the lexicon used to describe these facilities. An "Emergency Department" should describe an area staffed by EPs. A smaller hospital should be allowed to use FPs, but ought to be mandated to describe their emergent care area as an "Urgent Care Department" and strict transfer protocols should be in place and reviewed frequently. The current "Urgent Care" centers ought to be renamed "convenient care clinics" - since that is what they really are. Similar name changes have worked to define Trauma Centers and Pediatric EDs. ACEP and the AAFP should advetise these name changes and let the market forces drive the boat.

- H

 

[deleted6669]

I got short changed! My year only has 52 weeks 😡

EVEN WORSE.....our 2 yr program was 26 months......🙂
remember pa school is typically 100 weeks over basically 2 yrs +/- a few months while medschool is 150 weeks over 4 yrs.....lots of vacation and residency interview time in that medschool curriculum.....

 

[Apollyon]

I've worked with all three, and I've seen excellent clinicians among all three (and, bar none, SCARY NPs, PAs, and FMs - even two FM docs in the ED who are grads of the same program, in the same year - and one is a superstar that thinks like an EM doc and has it down as good as anyone, and the other is a bomb waiting to explode), and it's not nearly as clear an answer for me.

It's confidence and accuracy and acumen - and experience does make up for less schooling, leveling a lot of the field.

What a LOT of people here lack is direct applicability - who else has worked in the non-academic ED with colleagues that are EM-trained and FM-trained? This excludes FM-only EDs (the oft-mentioned "rural"), academic EDs and residents (FM, EM, and others), people that are office-based FM, and most students.

People get hung up on "ABEM certified" - my group is about 1/2 FM, who (mostly) do fast-track, with a few that do the double-covered intermediate ED shifts, and two that are credentialed by the hospital system to work individually in all parts of all EDs we cover. They have gotten there from hours worked in the department - a "practice track" that the hospital recognizes, irrespective of any board certification. Our group has a tertiary-care hospital ED, two suburban EDs, and a standalone ED. Anyone who says that FM cannot get an urban, tertiary-care EM job in this day and age is wrong, because I have objective evidence to the opposite.

However, no one from FM walks in the front door working everywhere, all the time, as I did.

Would that this were true...

The way of the world in many EDs still appears to be FM or nothing, until you guys either choose to practice in those un-sexy places, or train so many EM docs that they don't have a choice.

Meantime, pass me the T-sheet, I'm going in...

(and sounding like a broken record because NOBODY from the EM camp wants to respond to what I'm saying. Over. and over. and over.)

Lighten up, Francis (the movie was on yesterday)

Post #99, I believe I did, somewhat, respond to what you were saying. That was from 3pm yesterday.

An honest question - how many is "many EDs" that are FM or nothing? I'm guessing that your "n" is not that large, considering that there are >5500 EDs in the US.

People might be surprised to find who is in the rural ED - as much as people paint with one brush "FM or nothing", one day when I was a resident (off-service on Cardiology), we had a patient transferred in from one of those so-called "FM only" EDs - and I recognized the name of the transferring doc as a guy I'd worked with when I was a paramedic, and here he is, in the middle of nowhere, as an EP, ABEM-boarded, with 12+ years experience at the time. He previously had worked in a HIGH-volume suburban ED in upstate NY, and now is in the deep south.

 

[a_ditchdoc]

The way of the world in many EDs still appears to be FM or nothing, until you guys either choose to practice in those un-sexy places, or train so many EM docs that they don't have a choice.

Let's consider the flip side of this argument. There is currently a shortage of FP physicians in the US, primarily in the rural areas. Many FM physicians, just like EP's, do not want to live in rural areas away from the conveniences of a large city. Should we say that the reverse is true? Should EP's should be allowed to work in rural areas as FP physicians and be granted equal priveleges? What about other specialties willing to work in rural environments (ie radiology, OB, ENT)? Should they all be allowed to hang a FM shingle on their door because there is no FP trained physicin to do it?

I know the basics of what you are saying, and, in part, I agree. If EP's are not available, FP is the most closely related specialty and many times do a great job. But would the AAFP agree if other specialties began arguing for equality with FM, with minimal or no additional training? My guess is that they would not. We should not hold so tightly to double standards. Either you feel EM is a specialty, or you do not. Trying to use these thin veils based on "need" seems to make it a humanitarian mission for FP's and the AAFP rather than what it is; many FP's would like to work within emergency medicine but were not willing, or did not choose, to be residency trained. I find many of the argumants hypocritical. If the AAFP feels that a little extra training is good enough for FP's to work in ED's, then the reverse should be true. Perhaps a fellowship in FP lasting a year, or OTJ training, or perhaps even the perception of need in a rural place, should be the only requsites for EP's to hang the FP shingle.

Let's not diminish each others specialties. There is certainly a place for all of us to practice medicine within our respective roles.

 

[deleted87716]

Let's consider the flip side of this argument. There is currently a shortage of FP physicians in the US, primarily in the rural areas. Many FM physicians, just like EP's, do not want to live in rural areas away from the conveniences of a large city. Should we say that the reverse is true? Should EP's should be allowed to work in rural areas as FP physicians and be granted equal priveleges? What about other specialties willing to work in rural environments (ie radiology, OB, ENT)? Should they all be allowed to hang a FM shingle on their door because there is no FP trained physicin to do it?

Actually, this happens all the time. People tire of their specialty, or can't afford the malpractice, or move to a town where their specialty isn't needed, or whatever, and decide to take up general practice. They usually don't bother trying to pass themselves off as FPs, however, since the public wouldn't know what that meant, anyway. Their offices are usually called something generic like, "Anytown Family Care" or "Anytown Medical Associates." Doesn't matter...if you're the only game in town, you're the one they're going to come to see.

Do I have a problem with it? Not really. It's that, or nothing. More power to 'em.

 

[FoughtFyr]

Actually, this happens all the time. People tire of their specialty, or can't afford the malpractice, or move to a town where their specialty isn't needed, or whatever, and decide to take up general practice. They usually don't bother trying to pass themselves off as FPs, however, since the public wouldn't know what that meant, anyway. Their offices are usually called something generic like, "Anytown Family Care" or "Anytown Medical Associates." Doesn't matter...if you're the only game in town, you're the one they're going to come to see.

Do I have a problem with it? Not really. It's that, or nothing. More power to 'em.

Right, they don't pass themselves off as FPs. That is the problem. If there were a clear method to demonstrate to the public what the training of the provider treating them in an emergent care situation I think there would be far fewer objections. BUT - the fact that the public is stuck with whomever is "on" in an ED means that a higher standard should apply or a different lexicon (with appropriate safeguards) be adopted.

- H

 

[deleted87716]

Right, they don't pass themselves off as FPs. That is the problem. If there were a clear method to demonstrate to the public what the training of the provider treating them in an emergent care situation I think there would be far fewer objections. BUT - the fact that the public is stuck with whomever is "on" in an ED means that a higher standard should apply or a different lexicon (with appropriate safeguards) be adopted.

When I worked in the ER as a family medicine resident, my lab coat was embroidered "Family Medicine" right underneath my name. Nobody asked me about it even once.

The OB/Gyn folks, now...they'll tell a different story. 😉

 

[sophiejane]

Let's not diminish each others specialties. There is certainly a place for all of us to practice medicine within our respective roles.

See, this is where this argument goes downhill every time. Why do EPs see FPs practicing in the ED when there is a need for them to do so as somehow "diminishing" their specialty?

I understand what you are saying about the AAFP position. Perhaps that is what you mean about diminishing your specialty. But as Kent has said over and over, no one is talking about FPs working alone in trauma centers. When they do work in trauma centers, it is with EPs, not in place of them. Now, where there are shortages, particularly in rural areas, I think we all agree that an FP is better than nothing.

As to your comments about reversing the roles, I personally would have no problem with a board-certified EP doing a one year fellowship in outpatient medicine and then working in an underserved area as an FP. In fact, I'd welcome it. That way I wouldn't have to cover the ED. 😉

However, as I've said before, if you ask the people going into EM right now what their plans are, precious few are going to tell you they want to work in a rural ED. They want drama. They want "ER", the TV show. They want a "lifestyle" specialty. They don't want to see what you typically see in a rural ED, which is stuff that is easily handled by an FP, and they certainly don't want to live in a small town.

Hmmm. Maybe that's why things are the way they are...?

 

[sophiejane]

People might be surprised to find who is in the rural ED - as much as people paint with one brush "FM or nothing", one day when I was a resident (off-service on Cardiology), we had a patient transferred in from one of those so-called "FM only" EDs - and I recognized the name of the transferring doc as a guy I'd worked with when I was a paramedic, and here he is, in the middle of nowhere, as an EP, ABEM-boarded, with 12+ years experience at the time. He previously had worked in a HIGH-volume suburban ED in upstate NY, and now is in the deep south.

That's wonderful. As I've said, I hope that is the wave of the future. If I had wanted to be an EP in a rural area, I would have done EM. But I want to do FM in a rural area. Unfortunately, in my admittedly limited experience, and from what I've seen in my area, this is more likely than not going to mean covering the ED when it's my turn to do so.

Love,

Francis 😍

 

[kungfufishing]

See, this is where this argument goes downhill every time. Why do EPs see FPs practicing in the ED when there is a need for them to do so as somehow "diminishing" their specialty?

I understand what you are saying about the AAFP position. Perhaps that is what you mean about diminishing your specialty. But as Kent has said over and over, no one is talking about FPs working alone in trauma centers. When they do work in trauma centers, it is with EPs, not in place of them. Now, where there are shortages, particularly in rural areas, I think we all agree that an FP is better than nothing.

As to your comments about reversing the roles, I personally would have no problem with a board-certified EP doing a one year fellowship in outpatient medicine and then working in an underserved area as an FP. In fact, I'd welcome it. That way I wouldn't have to cover the ED. 😉

However, as I've said before, if you ask the people going into EM right now what their plans are, precious few are going to tell you they want to work in a rural ED. They want drama. They want "ER", the TV show. They want a "lifestyle" specialty. They don't want to see what you typically see in a rural ED, which is stuff that is easily handled by an FP, and they certainly don't want to live in a small town.

Hmmm. Maybe that's why things are the way they are...?

I went into EM. Not for a TV show, or Drama, or lifestyle. I just love the work. In a way, this post is illustrative of one of the differences in mindset between many in the two specialties. I am happy to see what you "typically" see in a rural ED or any other ED. It is sifted through awaiting the sicker patient. A large percentage of it could be handled by an FP or an untrained yet socially competent human or a well trained animal. However, even in podunk USA, if you want to work behind the the sign that says "EMERGENCY" on it and charge money, you should be prepared to recognize and manage emergencies. No matter where you are working, one could show up any second.

 

[a_ditchdoc]

When I say diminishing our specialty, I do not mean it in any way to denigrate FM. Some of the best, and most knowledgable, physicians I have worked with have been FP's. I just feel that what many people are saying, without actually coming out and saying it, is the EM is a specialty that others can step into with little additional training, a hobby if you will.

And while you talk only of rural ED's being manned by FP's, this is not necessarily the case. Some large groups are getting ED contracts and finding it financially advantageous for them to staff them with lower paid FP's. So long as the ED is staffed, and they save money that goes into their pockets, they could care less about the qualifications.

It is funny that you mention lifestyle, and then you infer that most EP's would like a large urban trauma center, like on TV, with bleeding, cursing patients, overflowing halls, and tons of drug seekers and indigent. I am not sure "lifestyle" and the TV version of ER coexist very frequently. A "lifestyle" WOULD include a small town, sleepy ED, with 16 patients a day. Throw a pond in back so I can fish between patients and I might just go there myself. Likewise, rural areas generally pay more than do large inner city programs.

 

[a_ditchdoc]

Actually, this happens all the time. People tire of their specialty, or can't afford the malpractice, or move to a town where their specialty isn't needed, or whatever, and decide to take up general practice. They usually don't bother trying to pass themselves off as FPs, however, since the public wouldn't know what that meant, anyway. Their offices are usually called something generic like, "Anytown Family Care" or "Anytown Medical Associates." Doesn't matter...if you're the only game in town, you're the one they're going to come to see.

Point well taken. I had never really considered that reality. But at least people have the option of seeing the GP or travelling further for a FP. When there is an emergency, you see who happens to be on in the ED.

 

[Apollyon]

I went into EM. Not for a TV show, or Drama, or lifestyle. I just love the work. In a way, this post is illustrative of one of the differences in mindset between many in the two specialties. I am happy to see what you "typically" see in a rural ED or any other ED. It is sifted through awaiting the sicker patient. A large percentage of it could be handled by an FP or an untrained yet socially competent human or a well trained animal. However, even in podunk USA, if you want to work behind the the sign that says "EMERGENCY" on it and charge money, you should be prepared to recognize and manage emergencies. No matter where you are working, one could show up any second.

Bingo. Spot on. As I've said in the past, 95% of my job can be done by protocol, technician, and machine. It's that 5% that I'm there for, and it's not in a convenient, single block, but spread out among all the trivial and/or BS complaints. Now, the key is, when the stuff hits the fan, who do you need there, in the ED? Someone who knee-jerk calls trauma when traumas come in, or someone who can actually manage it? Someone who can intubate a patients, and is neither afraid of it, nor unqualified. Likewise, I have a colleague that is not comfortable putting femoral lines in - and that is an EM/FM/IM/primary skill - not AT ALL specific to EM. Don't even consider the subclavian or IJ.

Now, that 5% can be learned through experience, but is taught from day 1 in EM residency.

 

[deleted87716]

I went into EM. Not for a TV show, or Drama, or lifestyle.

That's because there's no drama like family medicine drama. 😉

 

[a_ditchdoc]

KentW,

I like it....best post in a while...

ditch

 

[Faebinder]

That's because there's no drama like family medicine drama. 😉

Kent, you are falling behind on your pictures... the title should say FM not FP.

 

[dr. blue]

ok, first a brilliant statement: if you want to do em, do an em residency; if you want to do fm, do an fm residency. now, a not-so-brilliant situation. i've wanted to do em since reading the hippocratic oath, but apparently i was unmatchable. so i scrambled into fm. i guess now i'm a double-agent. thing is, i want to practice in a rural ed/urgent care setting. i keep reading over and over again that boarded em docs are phasing out fm-ers that are working in undesirable eds. how do i avoid always having to "look over my shoulder" as one poster put it? apply next year? em fellowship? urgent care fellowship? vaffunculo and write a novel?

 

[deleted87716]

Kent, you are falling behind on your pictures... the title should say FM not FP.

Aw, c'mon...give me a break. My Photoshop skills are limited. 😉

 

[Apollyon]

Aw, c'mon...give me a break. My Photoshop skills are limited. 😉

I cringed at the title of this thread when I saw it - 2 "non-PC" terms in 4 words (as it were).

Sophie gets props for keeping up FM, EM, and EP. I have a legitimate question, though - what is the right term to refer to the FM doctors (not the profession) - is it 'FM doctor' or 'FP' - as in 'Family Physician' (like the 'EP - Emergency Physician')? Or is it something else?

 

[deleted87716]

I have a legitimate question, though - what is the right term to refer to the FM doctors (not the profession) - is it 'FM doctor' or 'FP' - as in 'Family Physician' (like the 'EP - Emergency Physician')? Or is it something else?

It's pretty much the same as with EM.

EP = Emergency Physician
EM = Emergency Medicine

FP = Family Physician
FM = Family Medicine

The term "family practice" is as obsolete as "emergency room," though it's still (ab)used. 😉

 

[sophiejane]

ok, first a brilliant statement: if you want to do em, do an em residency; if you want to do fm, do an fm residency. now, a not-so-brilliant situation. i've wanted to do em since reading the hippocratic oath, but apparently i was unmatchable. so i scrambled into fm. i guess now i'm a double-agent. thing is, i want to practice in a rural ed/urgent care setting. i keep reading over and over again that boarded em docs are phasing out fm-ers that are working in undesirable eds. how do i avoid always having to "look over my shoulder" as one poster put it? apply next year? em fellowship? urgent care fellowship? vaffunculo and write a novel?

Sounds like you may be channeling Pandabear....

If you really want to do EM, I'd say do a year then try to switch, a la PB.

If you are happy with urgent care, and can accept that you may not be employable by an ED (even a rural one--I'm nothing if not realistic), then stick with FM.