corpsmanUP said:
But there are excellent FM docs who have become incredible EM docs by virtue of hard work and dedication. Many of them interviewed me on the interview trail.
James Holliman MD at Penn State
Nelson Perret MD at LSU
Mark Graber MD U Iowa
See, now you are putting words in my mouth. There is NO QUESTION that EM, as a profession, has been built by those who did not train in EM. There is NO QUESTION that these people, many of whom are the leaders of our profession, are fantastic EPs. But the "practice pathway" is closed. And these fine physicians have worked incredibly hard to define the body of knowledge needed to be an EP and decided on the timeframe needed for that training. Who am I to argue?
corpsmanUP said:
These people literally built emergency medicine as we know it today. Yes there may be a time when there is no room in the profession for them, or for any other FM trained docs to work in the ED.
Again, you are putting words in my mouth. I am not suggesting that we force out our fathers, but rather that there is a difference between EM now and EM when those people trained.
corpsmanUP said:
But for those who have no other option simply due to competition, there is nothing wrong with holding out hope that they can be trained to do respectable EM work in the rural setting.
Now we will just flat out disagree. Emergency medicine is a specialty. Period. You can not just "ease into it" with a little "extra" training. Nor do I believe that with a fellowship I should be allowed to practice FM.
corpsmanUP said:
There are lots of small private rural hospitals in my state that have some scary old fogey GP's covering the ED. I used to volunteer as a medic in a rural county here in Texas where we have a vacation home. Sometimes I would bring in patients on the truck and literally have to walk some FMG through an ACLS algorithm. I don't know if you have ever taken a patient to a place like this, where they might have 20 beds in the entire hospital and 3 ED bays. But I can tell you from personal experience that I would have given anything for a doc boarded in ANYTHING and would have fasted for 3 days straight in gratitude to find one working with an FM EM fellowship year under their belt.
And...
Look, I am not saying that these feelowship do not provide additional training. They do. what I am saying is that the training they provide is less than that of a residency. and, given the lack of support for these fellowships by the EM leadership, there are no standards for training nor metrics for assuring competancy - so we are only
assuming they leave a graduate beeter equipped to work in a rural ED.
And, my point was not that these place don't exist but rather "The only places left hiring FPs to do EM are so small that either the EM shifts are part of a larger FP schedule (i.e., each FP in a group pulls ED shifts in a clinic/hospital they are responsible to) or they are so desperate for help that any licensed physician would be hired (i.e., there is no competition for the job, ergo no "edge" to be gained by the fellowship)." Which is the picture you paint.
corpsmanUP said:
Its just too early FF to expect that this model cannot work for far out places. I realize you are from the great state of Illinois, but down here we have counties bigger than the entire midwest!! 😉
Lucky for you size doesn't matter...
😛 This is not a question of "rural model" or not. Downstate Illinois is very rural too. But the OP was asking how to proceed. Someone opined that these fellowships might be a good way to go. They aren't - for the reasons listed above. I am not suggesting that every ED in the entire country will, or even should, have a BE/BC EP. What I am suggesting is that as a matter of job security, an FP attempting to make a career of EM without a residency will work under a professional "Sword of Damocles" for their entire lives, not a way to go. To say nothing of the increased liability.
corpsmanUP said:
If your daughter ever grows up and decides to go to college at the great University of Texas, she'll likely experience driving across our state for hours without seeing anything but a cactus or a Hereford. You'd be happy to have one of these FM docs who had this training if she took ill or was in an accident. Because I can swear to you that you wouldn't want that old lady from Hungary! And there are lots like her.
Don't worry, that isn't going to happen (but I generally find it distasteful to imagine ill befalling family or friends).
corpsmanUP said:
FM docs who take this route know what they are getting into.
No, actually, they don't. I, for one, was heavily recruited by FM programs who assured me that with an EM fellowship I could work in any ED I wanted. I knew better - but I have two classmates who didn't. According to the thread I linked in my post, that experience is not unique.
corpsmanUP said:
They realize it is a long shot, buts its the only option some of them have. I for one respect them. There are lots of people in this world who are placed in positions they may not necessarily be perfectly qualified to do, and often these are on the front lines of medicine as we know them. No city in the US would ever allow their ALS units to be run by basic EMT's, but in the military sometimes that happens. I was a 19 year old E-2 corpsman taking care of 60 Marines in the Gulf. I was carrying **** I didn't even know how to dose and equipment I had been shown once how to use. The learning curve is steep in these environments, but its the only choice.
But this is a bit different. There is no urgency of battle, nor other expidiency of need, nor financial or cost restriction (as in your EMS example). The training the OP wants / needs is available.
corpsmanUP said:
BKN made a good point about it taking maybe 5-10 years to get up to speed to be the best doctor you will ever be. The unfortunate reality of life though is that somewhere in this country and even on the modern day battlefields every day, there is some poor soul who's life is depending on someone who may still be on their first five thousand patients.
Yep, that is true. But BKN's statement applied to the EP after training in EM, not an FP. And many, if not most, new EPs will have resources, be they colleagues or learning tools, to draw on to flatten the learning curve and reduce patient risk. I am not saying that as an EM residency graduate I will be infalliable, nor I am suggesting I will not have a great deal of learning yet to do. I am saying that EM is a specialty, with a recognized board, residency programs, and a well defined body of knowledge. If someone wishes to practice it, they should utilize these pathways.
Ask yourself if this were a specialty besides EM, would you make the same suggestion? That is, if someone didn't have the grades/stats to do ortho, should they go into FP in the hopes of opening an ortho clinic in a small town? There is no difference except that orthopedics has been around longer. FPs learn to examine injuries, reduce fractures, cast and splint, perform basic surgery, and provide followup care. So why not start up an FP ortho fellowship?
- H
