spitfire5454

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To make a long story short, I am a 2nd yr fp resident in a hospital whose only other residency program is er. I have been offered a rural er job that is going to be hard to turn down. 150-170/hr, big signing bonus, loan repayment and monthly stipend while still in residency. Probably 4 yr contract. My third year in residency would be heavy in er. My question is regarding job longevity. I'm a firm believer in "you can't do it all". I'm worried that if I do this for 6-8 years, most of my fp training will be outdated/forgotten. Obviously I will never be em boarded, and most city er's require boarded docs. Do unboarded docs have a shot if they have a lot of experience? I'm worried of doing this for like 10 yrs, then they don't renew my contract or something, now I'm stuck: I'm not qualified to do what I've been doing for the last decade, and I'm no longer any good at what I am qualified to do. Is this a valid concern? What do older non boarded er docs do when they get let go, and that's all they've known for the last 20 yrs? Any thoughts?
 

kungfufishing

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You are worried about forgetting your FP training but comfortable taking a job in a specialty in which you are not trained? I dont intend this to be snide, but think about what you are saying. Why not an FP job for which you are trained and can be boarded?
 

Tiger26

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To make a long story short, I am a 2nd yr fp resident in a hospital whose only other residency program is er. I have been offered a rural er job that is going to be hard to turn down. 150-170/hr, big signing bonus, loan repayment and monthly stipend while still in residency. Probably 4 yr contract. My third year in residency would be heavy in er. My question is regarding job longevity. I'm a firm believer in "you can't do it all". I'm worried that if I do this for 6-8 years, most of my fp training will be outdated/forgotten. Obviously I will never be em boarded, and most city er's require boarded docs. Do unboarded docs have a shot if they have a lot of experience? I'm worried of doing this for like 10 yrs, then they don't renew my contract or something, now I'm stuck: I'm not qualified to do what I've been doing for the last decade, and I'm no longer any good at what I am qualified to do. Is this a valid concern? What do older non boarded er docs do when they get let go, and that's all they've known for the last 20 yrs? Any thoughts?
Older docs were grandfathered in because EM is a relatively young specialty, however, that option is no longer available from my understanding. From here on out, only EM trained physicians will be eligible.
 
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spitfire5454

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You are worried about forgetting your FP training but comfortable taking a job in a specialty in which you are not trained? I dont intend this to be snide, but think about what you are saying. Why not an FP job for which you are trained and can be boarded?
Quite the contrary, Im approaching this extreme caution. I'm not that comfortable. The er attendings at my program say that i should do fine with the training I have for the acuity of the cases I will see there, and keep in mind that my final year will have integration with the er program. My fp attending say that fp have worked in er before em was a residency, so it is obviously doable, although not ideal as er residency is obviously more specialized. The problem is that no bc/be wants the job and they need somebody. Personally The only that is not that comfortable with the idea is me
 

Groove

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For starters, you're posting this on an EM forum and you can gander a wild guess as to how most of us feel about FP's taking a job to work in our specialty with no EM residency, formal training, or board requirement, regardless of the location...About the same way you would feel if I was posting on the FM forum about taking a sweet gig in a FM clinic somewhere after a few months elective exposure in family medicine my last year of EM residency...and I should be able to carve out a pretty good FM career...right guys??

Think about it. You're wanting us, of all people, to assuage your fears of not being able to enjoy a healthy and long term EM practice as a FP? Really? Wouldn't you probably get more constructive advice on the FM forum?

Are you interested in EM? If so, do one of your FM fellowships in EM and get some more training and then work in one of the rural or community ER's that have a difficult time attracting BE/BC physicians. Are you interested in the money? If that's the case, then open up a cosmetic/laser boutique practice somewhere where it's cash up front and rake in the money and forget the ER altogether.

I guess I just don't understand your motivations... If you want to work in EM long term, but are an FP with no intention of going through a 2nd residency or doing one of your "EM fellowships", then I'd say you definitely have a dilemma and cause to worry about longevity. If you're only attracted to the money and have loans to pay off, and we all understand those motivations, then it seems like you've got plenty of equally lucrative options working outside the ER as an FP physician if you just get a little creative with your practice.

It sounds like you should be able to handle 95% of what you will probably see in this rural ER, but what about the 5% that you won't be able to handle? What happens to those patients?
 
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spitfire5454

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For starters, you're posting this on an EM forum and you can gander a wild guess as to how most of us feel about FP's taking a job to work in our specialty with no EM residency, formal training, or board requirement, regardless of the location...About the same way you would feel if I was posting on the FM forum about taking a sweet gig in a FM clinic somewhere after a few months elective exposure in family medicine my last year of EM residency...and I should be able to carve out a pretty good FM career...right guys??

Think about it. You're wanting us, of all people, to assuage your fears of not being able to enjoy a healthy and long term EM practice as a FP? Really? Wouldn't you probably get more constructive advice on the FM forum?

Are you interested in EM? If so, do one of your FM fellowships in EM and get some more training and then work in one of the rural or community ER's that have a difficult time attracting BE/BC physicians. Are you interested in the money? If that's the case, then open up a cosmetic/laser boutique practice somewhere where it's cash up front and rake in the money and forget the ER altogether.

I guess I just don't understand your motivations... If you want to work in EM long term, but are an FP with no intention of going through a 2nd residency or doing one of your "EM fellowships", then I'd say you definitely have a dilemma and cause to worry about longevity. If you're only attracted to the money and have loans to pay off, and we all understand those motivations, then it seems like you've got plenty of equally lucrative options working outside the ER as an FP physician if you just get a little creative with your practice.

It sounds like you should be able to handle 95% of what you will probably see in this rural ER, but what about the 5% that you won't be able to handle? What happens to those patients?

dont get me wrong, im not trying get anyone to "assuge my fears", i was just hoping for some discussion as i think its a valid concern. I knew that it may rub some the wrong way, posting in this forum, but i figured the FPs that work ER would post here, not in the FP forum. As far as motivation, yes it money at this point. I have a lot of loans and a family to support. Its by far the best gig ive found, but i guess thats the point of incentives to get providers out to the rural area. sorry to offend anyone, just trying to look at this from as many perspectives as i can, good and bad. and for the other 5% (which i agree with BTW), i do believe there is a BC er there at all times as well.
 

emedpa

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and for the other 5% (which i agree with BTW), i do believe there is a BC er there at all times as well.
I wouldn't worry about it then...you are essentially filling a double coverage slot that at many places would be filled by a pa....as far as losing your fp skills, it might be worth your while to work a few days/mo at a free clinic or similar setting so you remember how to manage bread and better fp conditions like htn, dm, cholesterol and thyroid issues, etc.
at one of my jobs I work in the capacity you describe( being comfortable with 95%) at a rural facility as double coverage with a group of docs which are mixed fp/im/em folks. this group uses a lot of docs who are "primary care boarded with em experience". I think you will always be able to get such a job(rural/underserved em) but be aware you probably will not be able to work em in a major metro area without em board certification.
 

pratik7

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i agree with emedpa. I dont think there is rocket science to managing chest pain, SOB or vaginal bleeding. I would worry about the tough airway, central line, chest tube and trauma pts that you may not have been exposed to. Having an EM physician with you would def help and i think in that case it is doable. I also wouldnt be fooled into thinking that at a low volume rural ED you wont see sick people. It is actually more frightening in a place like that cause you dont have specialty backup and the nurses arent well versed in seeing the sick.

A viable alternative would be working in an urgent care clinic. In that setting you could also do 1-2 days a week of primary care and have the best of both worlds.
 

Jarabacoa

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For the forseeable future, there are going to be plenty of jobs in rural USA for family practice doctors.

You've got to be prepared for the rural atmosphere. In large cities, people don't know much about their local hospitals. In small cities and rural towns, EVERYBODY knows EVERYTHING. Every bad outcome is broadcast far and wide. Every bad experience (lets face it, there are a lot in rural america) is told to hundreds of other people, who pass on the gossip.

Think about the paradox of city life. My grandma lived in Las Vegas for 10 years. She lived within one mile of tens of thousands of people. She knew one of her neighbors. That is it. The others she didn't interact with. In a small place, especially after working in the ER for 5 years, the entire community is familiar to you and you are very recognizable. After 2.5 years, I can't show my face at any of the fast food joints. I know I would get loogies in my burger. I went to a fishing derby with my kids at a local pond a couple of months back and it was like the Whose Who of ER drug-seekers and frequent fliers.

Small town politics are really brutile. These people are one generation out from people who shot each other over cattle rustling. I know because so am I. The kind of grudge-holding, vindictive attitude that created the Hatfield and McCoys is still alive and well in rural america.

One mistake or mismanaged conversation with a prominent town leader can sink your career and make practicing in that community intolerable. I sincerely believe that it is really hard to live in the same small community where you staff the ER.

Hospital politics are brutile everywhere you go. They are worse in places that have a tough time recruiting quality, experienced CEOs, physicians, and nurses. Press-Ganey scores are very low at these hospitals, and they are all desparate to get them higher.

The resultant transient nature of small town ER positions makes for a tough family life. As an FP, you will pretty much be relegated to those kind of positions for the rest of your life and your family needs to be aware of that.

I would love to be wrong on this... anyone else have a different experience?
 
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crewmaster1

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Yes an FP may be comfortable seeing many of the cases that come into a rural, small volume ER; but, what about those few cases that have serious life threatening emergencies that you are not comfortable with. I moonlight in a small rural ER. You should realize that you often have very few resources and thus must be even more comfortable in this setting.

Some questiosn to think about:
How many standard intubations have you done? How many trauma airways have you completed? What about that person who comes in with angioedema? Have you ever done a fiberoptic nasotracheal intubation? And if you can't get that on your first time playing with the scope, are you comfortable doing a cricothyrotomy? What about pediatric airways? Neonate?

The good old cardiac arrest is easy, but what about the almost dead? Are you comfortable with all the different central lines? What about that intravenous pacer when the patient won't capture well with transcutaneous pacing?

What about ortho stuff? Are you comfortable with all of your reductions? What about procedural sedations and blocks?

While you will be making great money at this new job in the ER, it won't be great for your family when you end up with a malpractice lawsuit for a case gone bad. Not saying you wouldn't do ok, but I have seen and heard about some horrendous stories about the non-EM trained physicians where I moonlight. Most of the time they are OK, but there are some rough cases that role through and you are often the only person in the house.
 

EM2BE

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About small towns - I've seen it work (even with 24 hour shifts in middle of nowhere midwest) - just don't live near the location of work. Solves some of the small town problems. Sometimes it's easier to deal with people and other times it's more difficult. In really small towns, most have family physicians, therefore come in only when sick.