FP or ER?

[deardr07]

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I was wondering if you convince me that ER is better than FP. I was in a tracked program for FP and completed my internship. I then took some time off and am considering going into ER instead. I loved my ER attendings during that rotation in my internship and I loved the ER itself. I hated clinic but I am not sure if it was the people but I found it boring and I didn't like going through charts to see if woman had her mammo, her pap, her colonoscopy...I like urgent care type things. So heres my question, for those of you who picked ER and were considering FP, what made you choose ER? The one thing that holds me back from doing ER is I might want to have my own office and work semi descent hours (no night calls). Also thinking of doing fellowship that can do from FP or ER. I would have to repeat my internship year if I switch to ER (most likely) and that would stink; What do you think? Also what is a stereotypical FP and ER person like, maybe I should just go to the one which I am more like...at this point I just feel confused. I don't want to regret doing FP even though I could do a fellowship in ER....any thoughts would be great...and no haters please!

 

[Apollyon]

I am not an "hater", but the title and elements of your post just make me wonder how much you have researched this issue. The people that worry about such things have pushed - hard - to be referred to as "family medicine" and "emergency medicine". If this has not penetrated to the level of you being a med student, then I hope that the balance hasn't given you other bad advice.

I mean, I'm just sayin'.

 

[JackADeli]

My friends in Family Med have informed me the route of family medicine does not exclude the possible career in emergency medicine.

1. it is quite common for the ERs to be staffed by family med doctors.
2. i was told there is some route to ultimately be double boarded

I would love to here from folks on this.

 

[SoCuteMD]

My friends in Family Med have informed me the route of family medicine does not exclude the possible career in emergency medicine.

1. it is quite common for the ERs to be staffed by family med doctors.
2. i was told there is some route to ultimately be double boarded

I would love to here from folks on this.

Well, the only route to being double boarded is to complete a joint FM/EM residency.

As far as the OP - if you have to be "convinced" to go into EM, it's likely not the field for you. EM is a great field for a number of reasons, but it's a tough field for a number of reasons as well. In fact, I might just strangle the next person who tells me how "laid back" EM and EM residency are.

 

[BADMD]

The US is slowly moving to EM trained physicians in the Emergency Department. FP trained docs who want to work in the ED are going to increasingly find their options are podunk no-where and urgent care. I don't believe any of the FP fellowships lead to board certification in EM.

If you want to have your own office doing primary care, then ED is not for you. There are some EM fellowships that will let you have an office based practice, but if you do some EM, you are going to be stuck doing night call like the rest of us.

 

[JackADeli]

eligibility requirements
updated september 2008

to be eligible for certification in emergency medicine through the board of certification in emergency medicine (bcem), the applicant must:....


Be qualified under one (8a, 8b, or 8c) of the following:

• completed an acgme or aoa-accredited residency in emergency medicine. (meeting this requirement also satisfies the residency requirement specified in item 7.)
• the applicant must have practiced emergency medicine on a full-time basis for five (5) years and accumulated a minimum of 7,000 hours in the practice of emergency medicine and satisfy either i or ii:
  • completed an acgme or aoa-accredited primary care or anesthesiology residency (meeting this requirement also satisfies the residency requirement specified in item 7.)
    
    or
  • be certified in a primary care specialty or anesthesiology by an abps, abms, or aoa-recognized board of certification (meeting this requirement does not satisfy the residency requirement specified in item 7.)
• graduate training program: Completed either a 12 or 24-month emergency medicine graduate training program approved by the bcem. Physicians completing a 12-month graduate training program must have practiced emergency medicine on a full-time basis for an additional 12 months, before or subsequent to completing the graduate training program. (this graduate training program does not constitute a residency program, and does not fulfill the residency requirement specified in item 7.)
  
  

http://www.abpsus.org/certification/emergency/eligibility.html
Again, I think given the broad nature of EM residency, a family practice physician that then spends a good deal of time in the ED should be more then qualified. The truth is that most FP residencies have a training paradigm that very much mirrors emergency medicine training.

I won't get into a pee pee contest on this because.... well, I am not going to be an FP seeking ER certification. I'm a board certified GSurgeon that has done my share of trauma. I just post this cause.... ER is a relatively new entity in itself. Is a broad reaching specialty that depends highly on being trained by numerous other specialties such as Fam Med does too.. The objective would seem to be having ERs staffed by highly trained physicians with broad experience to help in initial diagnosis and/or stabilization and or treatment...

The US is slowly moving to EM trained physicians in the Emergency Department....

given the relative youth of Emergency Medicine as a formal specialty, if this is true then it is not "slowly moving" but rather very fast move. My take on ED is that it has in the past been staffed by internal medicine, pyramided out surgery residents, retiring surgeons, and the like....

 

[SoCuteMD]

http://www.abpsus.org/certification/emergency/eligibility.html
Again, I think given the broad nature of EM residency, a family practice physician that then spends a good deal of time in the ED should be more then qualified. The truth is that most FP residencies have a training paradigm that very much mirrors emergency medicine training.

I won't get into a pee pee contest on this because.... well, I am not going to be an FP seeking ER certification. I'm a board certified GSurgeon that has done my share of trauma. I just post this cause.... ER is a relatively new entity in itself. Is a broad reaching specialty that depends highly on being trained by numerous other specialties such as Fam Med does too.. The objective would seem to be having ERs staffed by highly trained physicians with broad experience to help in initial diagnosis and/or stabilization and or treatment...given the relative youth of Emergency Medicine as a formal specialty, if this is true then it is not "slowly moving" but rather very fast move. My take on ED is that it has in the past been staffed by internal medicine, pyramided out surgery residents, retiring surgeons, and the like....

Um, I'm not even sure what that is that you posted, but I know it's not from ABEM - which is the board certification standard recognized throughout the US for emergency medicine.

The argument that FP residencies have a paradigm that is similar to that of EM residencies is simply false. I challenge you to put an EM curriculum and an FP curriculum side by side and then say that they look similar.

 

[JackADeli]

Um, I'm not even sure what that is that you posted, but I know it's not from ABEM - which is the board certification standard recognized throughout the US for emergency medicine...

OK. As I noted, I'm neither FM nor EM.

I appreciate your correction.... this is what I found:

https://www.abem.org/public/_Rainbow/Documents/Guidelines%20for%20Combined%20Residency%20Training%20in%20EM-FM_FINAL.pdf

as I thought, fairly young specialty board:
https://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__3573/DesktopDefault.aspx


Out of curiousity, I will continue to look for more stuff.

 

[JackADeli]

...The argument that FP residencies have a paradigm that is similar to that of EM residencies is simply false. I challenge you to put an EM curriculum and an FP curriculum side by side and then say that they look similar.

I actually did just look up UofMichigans 4 yr EM residency and Dukes FM residency. There are quite a few similarities. I never said identical. Those are just two I looked at but I am sure things vary from program to program. Depending on nomenclature of rotations and how electives are used can obviously impact the overlap/similarity. But, again, I never said identical.

 

[SoCuteMD]

I actually did just look up UofMichigans 4 yr EM residency and Dukes FM residency. There are quite a few similarities. I never said identical. Those are just two I looked at but I am sure things vary from program to program. Depending on nomenclature of rotations and how electives are used can obviously impact the overlap/similarity. But, again, I never said identical.

I guess I'm not sure how you see them as similar. Is there overlap? Sure. Everyone does some inpatient peds, some form of newbon care (nursery vs NICU), MICU, some form of inpatient cardiology, some form of surgery (trauma vs inpatient floors), obstetrics, and some time in the emergency department. Overall, however, those overlapping rotations account for less than a year out of 3 or 4. The FM people never act as seniors in the ICU, the EM people do. The FM people spend about 1/2 of their last two years in an ambulatory setting. Not to mention that one of the first statements on Duke's Curriculum Overview page is something to the effect of "We focus on chronic disease management."

 

[Arcan57]

BCEM (Board Certification in Emergency Medicine) is a certificate from the American Board of Physician Specialties, "the third largest multi-specialty physician/surgeon certifying entity" http://www.abpsus.org/about/index.html

The ABPS would like you to believe that BCEM is equivalent to ABEM. Having worked with BCEM physicians, I have not found this to be true. The issue is that so much of what makes someone a good emergency physician is being prepared to deal with the rare and deadly. And one year of "EM fellowship" just doesn't provide enough formal instruction or enough time in the ED to familiarize yourself with management of the uncommon disease entities we're expected to handle. And it's very difficult to make up for that knowledge gap and stay current on the latest treatments once you're out in practice.

JAD, even if the curriculum requirements may look superficially similar, the focus on those rotations are going to be different for an FP program vs. an EM program. Also, the educational requirements are naturally going to focus on different areas. 5 hours per week of EM didactics vs. FP didactics accumulate a substantially different knowledge base over the course of residency.

 

[deardr07]

thanks for info, especially from JAckADeli, you know I look at the ER's I have done my rotations in and only about 1/2 of the attendings are ER trained. The rest are IM or Surgery. The chair of ER at a the large community hospital in the NYC (wont say which one) is boarded in Surgery only and the other hospitals have IM boarded ER docs. I think there is a push (esp by the ER docs themselves) to have only ER docs in the ER but this is just not happening yet. It may in the future.
As for ER and FP being similar, they are, not the same. They are both primary care focused on jack of all trades. Of course we all know the differences.
And if you do urgent care, then FP is even more like ER.

 

[JackADeli]

...even if the curriculum requirements may look superficially similar, the focus on those rotations are going to be different for an FP program vs. an EM program. Also, the educational requirements are naturally going to focus on different areas...

I agree completely. I admittedly am speaking from a perspective of some ignorance. However, I was not intending to claim any equality in the training. My point is there is a significant parallel in the broad based foundation of knowledge in numerous specialties required by both these fields. As you note, how that base is focused will clearly differ.

What I am saying is that with a broad "jack of al trades" foundation, components can be added and or changed and focus redirected to go from straight family medicine to emergency medicine. It would obviously depend on program design. Suffice it to say, if a FM program spend numerous hours in the ED under the supervision of ER physician.... then spends additional time purely focused on EM, I don't believe it beyond capabilities to become competent in the field of EM.

 

[jbar]

Suffice it to say, if a FM program spend numerous hours in the ED under the supervision of ER physician.... then spends additional time purely focused on EM, I don't believe it beyond capabilities to become competent in the field of EM.

Spending numerous hours focusing on EM sounds a lot like doing an EM residency. Yes there is some overlap, which is why programs like EM/IM are 5 years, you can save a year by cutting out the overlap.

 

[SoCuteMD]

I agree completely. I admittedly am speaking from a perspective of some ignorance. However, I was not intending to claim any equality in the training. My point is there is a significant parallel in the broad based foundation of knowledge in numerous specialties required by both these fields. As you note, how that base is focused will clearly differ.

What I am saying is that with a broad "jack of al trades" foundation, components can be added and or changed and focus redirected to go from straight family medicine to emergency medicine. It would obviously depend on program design. Suffice it to say, if a FM program spend numerous hours in the ED under the supervision of ER physician.... then spends additional time purely focused on EM, I don't believe it beyond capabilities to become competent in the field of EM.

It's not *just* working in the emergency department that makes one an EM physician.

Don't forget trauma, critical care (adult and pediatric, intern and supervisory roles), orthopedics, toxicology, EMS. Or the 700+ hours of EM-focused didactics provided in a 3 year residency program.

 

[Arcan57]

JAD's reasoning stands up if you look at FM and EM as jack-of-all trades generalists. However, the true general practioner in the US doesn't exist to any appreciable degree. Emergency physicians are specialists, it's just that much of our specialized skill set is not apparent to our consultants. The surgeon I call down for an acute appy or the interventional cardiologist called for a code STEMI does not care that I'm seeing 10-16 other (new, undifferentiated) patients simultaneously, and if I do my job correctly they do not need to care. Efficient patient flow, appreciation of the dangers of a full waiting room, effective communication with consultants, etc. all take time and training to develop. Instead of specializing in a disease entity, organ system or a treatment modality we specialize in a phase of care. Now there can always be arguments about the perceived value of one specialty versus another, but patient care has improved with the introduction of EM as a specialty.

 

[thethom]

I would still argue that both EM and FM are generalist (not "specialist") roles; both involve care of all genders, all ages, and all disease presentations. What other residency program trains an individual for "just about everything?"

EM however focuses on a higher acuity and FM focuses on a higher chonicity (kind of like a track; EM could be considered a generalist with high acuity track and FM could be generalist with high chronicity track). Philisophically (forget for a minute what the ABEM and BCEM says) both have CONSIDERABLE overlap in terms of what you see day to day on the job, and EM will see plenty of runny noses, COPD exacerbations, and poor DM2 control, and FM will see plenty of broken bones, ACS, and precipitous deliveries in the office.

When choosing between the 2 for residency, you just need to consider when you are 50, whether you are ok with doing night shifts, or whether you would prefer to be on the golf course in the evening...(to me medicine was just a job, not a life.)

As for those interested in sports medicine, >90% of fellowships are within an FM residency program and prefer (yes I said prefer, the ABFM is the original administering board for the subspecialty) FM trained individuals as PCSM emphasizes the long term care of the athlete as well as acute on the field presentations.

Best of luck in your decision, both are great fields!

-Dr. T.

 

[Rendar5]

honestly, I don't see myself being trained to manage diabetes or hypertension, nor do I see FM as being trained to throw in central lines regularly, intubate patients, and run trauma codes. Now being able to handle the typical patient who comes in for acute care? sure, either one of us should be able to handle that no problem. But I don't really feel comfortable cross-covering that 10%-20% uniqueness to each field.

Now do I know older FP's who happily work in ED's? Oh hell yeah and I totally trust them on teaching me EM. but it's kinda different being grandfathered in and having 15 years of EM experience now working in a system largely composed of EM-trained physicians as compared with having 1 year of EM experience plus an FM residency.

 

[thethom]

honestly, I don't see myself being trained to manage diabetes or hypertension, nor do I see FM as being trained to throw in central lines regularly, intubate patients, and run trauma codes. Now being able to handle the typical patient who comes in for acute care? sure, either one of us should be able to handle that no problem. But I don't really feel comfortable cross-covering that 10%-20% uniqueness to each field.

I think you're totally right, however I'm sure you could manage diabetes or HTN to some extent (albeit not as good as an FM who has continuity with the pt), and I do feel comfortable placing central lines of every type, intubating, and managing SOME trauma, but I would NEVER claim to be as proficient at it as someone who does it day in and night out ie an EM physician.

Bottom line, we are both generalists.

 

[roja]

To the OP:

One is not better than the other. All you need to do is spend time in both environments and you will see that the 'overlaps' are pretty cerebral and the actual practice of each field has very little overlap. The pace, scope, lifestyle, patient relationships, practice environment, etc are very very different. Each one, important, and each one requires that YOU decide what fits best for what you want to do.

With regards to being FM resident training -> working in an ED, this is slowly eroding away.

You can argue the pluses and minuses to this philosophy until you are blue in the face. (we all know great FP's who have always worked in the ED, bad ones, and the same for EM trained physicians as well). The truth of the matter is, there is no more 'grandfathering' in for EM. You MUST complete a residency in EM to become board certified in EM. From a legal standpoint, many larger ED's will no longer be staffed by physicians who are not BE or BC in Emergency Medicine. Any half way decent lawyer will pull out standards of care and/or literature that shows outcomes are better when you have residency trained EM physicians working in EM. The places that do have non-em people in them, tend to be in smaller places that can't be filled by BC/BE EMP's.
The other issue is if you want to work where there are EM residents.

The RRC very clearly states that EM residents are not allowed to be supervised in the ED by faculty who are not BC in Emergency Medicine. Period. Non-grandfathered in faculty, regardless of how good they are, generally have to resign or move to non-clinical or fast track parts of the ED when residencies start.

So, the intellectual arguments are just that. You can argue generalists, you can talk about great or bad EP's/FP's.

The answer to your question is simple: Do you want to be an Emergency Physician or a Family Practitioner? One is not better than the other. Spend time in each. Figure out what is important to you, which one you loved to go to work at, and you will have your decision.

 

[melanoleuca]

JAD's reasoning stands up if you look at FM and EM as jack-of-all trades generalists. However, the true general practioner in the US doesn't exist to any appreciable degree. Emergency physicians are specialists, it's just that much of our specialized skill set is not apparent to our consultants. The surgeon I call down for an acute appy or the interventional cardiologist called for a code STEMI does not care that I'm seeing 10-16 other (new, undifferentiated) patients simultaneously, and if I do my job correctly they do not need to care. Efficient patient flow, appreciation of the dangers of a full waiting room, effective communication with consultants, etc. all take time and training to develop. Instead of specializing in a disease entity, organ system or a treatment modality we specialize in a phase of care. Now there can always be arguments about the perceived value of one specialty versus another, but patient care has improved with the introduction of EM as a specialty.

Exactly. I was talking to a internist the other day who asked me, "Doesn't it scare you to have a full waiting room, ambulances coming in, and twenty unknown patients 'cooking' at the same time?"

Well, no. It doesn't. Just another day.

 

[thethom]

The FM people never act as seniors in the ICU, the EM people do.

Not sure what you're basing this on, in 2nd year at my program we are seniors in the ICU (second of course to the PCCM attending). On my inpatient months (as an intern) I manage patients daily in the ICU (FM and IM seniors help with vent settings)

Bottom line, do you want mostly urgent/acute care, day and night shifts? Or do you prefer urgent/longer term management and 9-5 hours? For me, it came down to: can I see myself in the hospital at night at 50 years old?

Both can be great specialties if you go into it for the right reasons.

 

[jl lin]

And of course there are dual EM/FM residency programs--well, at least one I know of in DE and possibly another in LA or far west. They're five years. . .so, for a NT, that's a serious consideration.