Help, please? (med/peds working the ED)

[membername22]

Hi guys -

I'm a med 4 at a decent midwest medical school with an pretty good board score, solid LORs, plenty of non-pigeonholing volunteer and research experiences. Basically, if I applied broadly enough I think that I could match into most of the areas I'm interested in. My only problem is that choosing a specialty (ie, limiting my choices) makes me absolutely sick to my stomach.

Question: Can a med/peds residency graduate who certifies with both boards find a job in an emergency department? What about an ED at a big tertiary care center? What about an ED at a big academic tertiary care center? Would this require ABMS certification? How much less employable (notice I didn't say "less qualified") will I be compare to a board-certified EM resident?

I'm asking in the Emergency Medicine forum because I think you guys probably have a more realistic answer. While you are welcome to comment on "the appropriateness/effectiveness/qualifications of a med/peds resident in the ED" and "whether or not the ABMS certification is worth anything" or anything else you'd like to throw in there (and I promise I'll read it) - PLEASE answer my question about whether I would be employable in the ED.

Thanks a ton.

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[dchristismi]

The generic answer is that it depends. It depends on where you are willing to go. Wyoming? Yeah, you could probably work in an ED as a med-peds guys there.

Small rural areas that can't get ABEM-certified EM trained docs? Probably.
A big tertiary referral center? Probably not, but you never know. Not a sure thing.
A big academic tertiary referral center? Not so much.

My group only hires EM-trained docs, with the requirement that board certification is achieved within so many years. So if you wanted to come work with me, you wouldn't be employable.

If you really love just about everything, EM fits. Med-Peds still cuts out some. Are you a clinic doc, or do you prefer the hospital? (Which is one of the biggest differences between a Med-Peds practice and EM)

As someone far wiser than I stated once (It might have been DocB)... you can't be a stem cell forever.

Good luck

 

[Cerberus]

Question: Can a med/peds residency graduate who certifies with both boards find a job in an emergency department? What about an ED at a big tertiary care center? What about an ED at a big academic tertiary care center? Would this require ABMS certification? How much less employable (notice I didn't say "less qualified") will I be compare to a board-certified EM resident?

Well, then i'll say it for you, Medicine and Pediatrics trained physicians are much less qualified to work in an ED than an board certified EM trained physician. We think differently and our training is entirely different. While Med/Peds people think in days, we think in minutes and hours. While Med/Peds may know about the disease states we see in the ED, are you adequately trained to recognize them in an undifferentiated patient and then manage that patient in an acute setting? How comfortable do you expect to get with procedures in a specialty that is largely clinic/floor based? It's apples and oranges. If you want to be an ED doc either do an EM residency, an IM/EM residency, or a Peds EM fellowship following residency. I'm not arrogant enough to assume I know how to manage the longterm care of a patients blood sugar, htn, or make sure they are getting their immunizations on schedule and I find it annoying that you would assume that after spending 4 years in a floor heavy specialty that you could just come down to the ED and do what we do without additional training.

 

[corpsmanUP]

Well, then i'll say it for you, Medicine and Pediatrics trained physicians are much less qualified to work in an ED than an board certified EM trained physician. We think differently and our training is entirely different. While Med/Peds people think in days, we think in minutes and hours. While Med/Peds may know about the disease states we see in the ED, are you adequately trained to recognize them in an undifferentiated patient and then manage that patient in an acute setting? How comfortable do you expect to get with procedures in a specialty that is largely clinic/floor based? It's apples and oranges. If you want to be an ED doc either do an EM residency, an IM/EM residency, or a Peds EM fellowship following residency. I'm not arrogant enough to assume I know how to manage the longterm care of a patients blood sugar, htn, or make sure they are getting their immunizations on schedule and I find it annoying that you would assume that after spending 4 years in a floor heavy specialty that you could just come down to the ED and do what we do without additional training.

Come on dude, the OP clearly stated that they were asking the question genuinely all the while knowing they were in enemy territory. Your answer was freaking rude. Made some sense, but was rude. I think you owe an apology.

OP, the truth is that it may not be truly about who is more qualified, but it truly is about who is more employable. I work in a rural area where we have 6 docs, myself and one other EM boarded, 3 others EM boarded by grandfathering in with IM or FP certs, and one other who is Med/Peds and who happens to also be our director. He is the best of all of us and has been out of Med/Peds for about 7 years now. He never practiced anywhere but a level I ED from the time he left residency but he got into that job while he was in residency. So in essence his training was similar to ours as EM docs once he got out of residency. But this path is rare and one that will cause you many hours of grief when you want to change jobs. My group is currently trying to hire for an EM trained director and he will eventually find it harder and harder to find a different job. Sad, but true.

If you want to do EM, then just do EM. The ABMS specialty is not worth mentioning from a board cert standpoint. Not that some of them are not good EM docs, but it's a cert that has no credibility.

For what it's worth, I know a ton of friends who went Med/Peds, and all for the right reasons. Ultimately not one ended up utilizing both skillsets and they all have told me through the years that they wish they had done one or the other, or something altogether different. It's sort of that same mindset FM docs have when they want to save the world from cradle to grave, deliver babies, first assist on surgeries, until they realize the pay sux and they are stuck in a specialty with a lot of FMG's, and find the reality of FM boring and unfulfilling. Not the case for all, but certainly for many.

I personally can't find a reason why anyone would do Med/Peds unless they were wanting to sacrifice their wages to be a real family doctor with the ability to take care of most any patient type in a manner more proficient than most FP's who are less trained in my opinion.

 

[Arcan57]

Can you do it? Yes. My region doesn't have an EM program and it is not uncommon for residents in either straight IM or med-peds to express a desire to work in the emergency department after graduating. At our tertiary care center, only 3 of us are residency trained. So yes, for now, in many regions of the country you can be something other than EM trained and still be employable in an ED.

However, there are large chunks of core EM content that are not contained in the med-peds curriculum. My wife trained in med-peds, so I'm not talking out of ignorance on this point. Also, in the majority of practice environments, you will not see enough procedures to improve your monkey skills. Most EM residents will have hundreds of intubations, many in uncontrolled, "difficult" airways. I would guess most EM attendings don't intubate more frequently then every third shift, which isn't frequent enough to build up a skill. Video laryngoscopy and U/S guided central lines definitely make things easier, but most of the places that employ mainly non-EM trained docs will not have these tools.

And it may seems like line and tube skills aren't that critical compared to medical knowledge, but technical proficiency colors your decision making. As a referral center, we see plenty of people sent to us that needed intubated prior to transport (most commonly bad head bleeds) or were in hypotensive shock with a 22g IV because the referring doc didn't feel comfortable performing these procedures. It's easy to choose the right board answer, but when you're looking at a 350 lb guy with no neck it's also easy not to do the right thing because you think it's going to be hard.

 

[Cerberus]

Come on dude, the OP clearly stated that they were asking the question genuinely all the while knowing they were in enemy territory. Your answer was freaking rude. Made some sense, but was rude. I think you owe an apology.

My response wasn't meant to be rude, it was meant to be truthful. Med/Peds is not an equivalent to EM. Are there still non EM trained physicians working in EDs? Sure, but I wouldn't count on that lasting forever. As medicine progresses skillsets become more specific. When it comes to providing care in an ED an EM trained physician is going to provide better care than someone who spent most of their training focusing on an entirely different aspect of care than what is found in the ED. Further, once you are out of residency and that deficiency in knowledge shows, there is a good chance - as many EDs that hire non EM boarded docs will be single coverage - that there will be no one to back you up. Who suffers the most from this? The pt unlucky enough to end up in your ED.

 

[Venko]

Hi guys -

I'm a med 4 at a decent midwest medical school with an pretty good board score, solid LORs, plenty of non-pigeonholing volunteer and research experiences. Basically, if I applied broadly enough I think that I could match into most of the areas I'm interested in. My only problem is that choosing a specialty (ie, limiting my choices) makes me absolutely sick to my stomach.

Question: Can a med/peds residency graduate who certifies with both boards find a job in an emergency department? What about an ED at a big tertiary care center? What about an ED at a big academic tertiary care center? Would this require ABMS certification? How much less employable (notice I didn't say "less qualified") will I be compare to a board-certified EM resident?

I'm asking in the Emergency Medicine forum because I think you guys probably have a more realistic answer. While you are welcome to comment on "the appropriateness/effectiveness/qualifications of a med/peds resident in the ED" and "whether or not the ABMS certification is worth anything" or anything else you'd like to throw in there (and I promise I'll read it) - PLEASE answer my question about whether I would be employable in the ED.

Thanks a ton.

I definitely understand that choosing a specialty is difficult and I wish you all the best in your pursuit. You are asking good questions and my opinions to them are below. With that said, I think to assume that EM and Med/peds are similar isnt quite accurate because I think there are some key mentality differences. EM is the specialty of the undifferentiated, crashing or impending crashing, life or limb threatened patient. Although it involves all ages and both genders, it differs from Med peds. Med Peds is a clinic based, follow up driven, preventative and long term health care specialty. There is little procedural experience within a med/peds residency as well. EM truly is its own specialty and if you want to do yourself and your patients service in Emergency medicine, consider applying and training in Emergency Medicine; I have enjoyed my career thus far and I think you may too. Although I do agree with cerebrus that Med / Peds physician is less qualified to work in an ED, I would add that EM physicians are less qualified to work in an office setting with preventative and long term care being provided. No insults intended, just simply different specialties.

In any case, if you do finish med / peds you will find jobs in EDs. You wont be able to work in larger centers and academic centers. You wont be able to be faculty to EM residents. Generally, non EM trained physicians are paid less as well. I have seen some statistics that EM trained physicians have fewer (not zero) malpractice claims against them and generally have better outcomes with lower cost of care. Job satisfaction in EM is rumored to be higher when formally trained in EM as well. (Take it for what it is as it is only just rumor).

Overall, good luck in your future!

Cheers,
TL

 

[membername22]

Thanks to everyone for the candid and gracious replies - I appreciate those who read my question thoroughly enough to realize what I was asking. I've been through the difference countless times with several advisors and I've heard plenty of opinions on who is trained well enough for what. However, I just need every piece of information I can find to make my most informed decision.

Cerebrus - despite your best efforts, you did answer my question ("many EDs that hire non EM boarded docs...."). Ha!

To everybody else - genuine thanks for answering my question and I don't resent y'all getting a little opinion in there, too. Thanks also for the heads up about ABMS.

I genuinely believe that the person is more important than the title of the training - I think it would be entirely possible for me to be a proficient ED physician somewhere down the line after Med/Peds training. That said, I recognize that it would be quite a ways above and beyond my training. Don't worry, I'm not coming for your job. I'm just looking for some facts that people have a HARD time giving. It's really hard to look your advisor in the face and say "Look, pal, you've told me 10 times how much better-trained an EM-boarded doc would be.... but I want to know what's possible, not what's typical."

Thanks again.

 

[Apollyon]

The gist is that it is specialty training. As one poster stated above, there's a different focus - immediate care vs chronic. There is a guy that worked in the group I used to, who did Med/Peds 20 years ago at a place that didn't have EM. He did 3 months of trauma with his 3 electives, and was the first person EVER to do this at his hospital. He grandfathered in to EM and Peds EM.

It's like pounding a nail - the best thing is a hammer. You're asking about shoes. Sure, you can pound a nail with a shoe, but that's not for which it was made. Once the nail is pounded, with the hammer, you go on to the next one. The shoe, you wear chronically. You may get good with pounding nails with your shoe, but you may not. The chances are much better that the nail will be hit cleanly with the hammer, although the hammer cannot work as footwear (or, just like EM as primary care, if you do, it WILL be painful).

 

[deleted77919]

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[Rendar5]

It's possible to do this and you'd be a "meh" EM doc with several major deficiences for many years,
Now if you're ok being below average for many years, that's fine. But if you are going to do this route and want to be good at it, might I recommend that you go out of your way during residency to:

get enough central lines to be comfortable putting one in all 3 locations within 5-10 minutes.
Get enough intubation practice to be comfortable with crash airways that are not optimal, and knowing when you should and shouldn't RSI airways.
Get practice splinting and suturing and wound care so those don't take you too long. Spending a few days with basic material in a fast track on days off should get you that.
Get ATLS certified (since you will be certified at least for PALS and neonatal resuscitations as med-peds) so you know how to handle a trauma.

You need ENT, ob-gyn, urology, and opthalmology experience too in terms of acute issues so you can handle those cases that come along. Most of the acute issues in these fields you will not encounter as Med-Peds.

Although ultrasound is a big part of EM nowadays, that is actually somethign you could get away without knowing how to do yourself. And if you changed yoru mind on that it doesnt' cost too much money to go to one of the many seminars out there.

 

[membername22]

It might be better to ask "What's wise?" I mean, there's nothing stopping you or anyone else from doing one year of residency, getting your unrestricted state medical license and opening membername22's drive through brain surgery shack. Yeah, it's impractical, but as far as the state is concerned, entirely possible with your license to practice medicine and surgery. Doesn't mean it's a good idea.

With all due respect, and definitely recognizing your point (for the dead horse it is) - I couldn't find a n/s group to work for after an internship. I could also probably be successfully sued for a perfect outcome if I attempted operating. As a med/peds graduate, I CAN get hired.

It's possible to do this and you'd be a "meh" EM doc with several major deficiences for many years,
Now if you're ok being below average for many years, that's fine. But if you are going to do this route and want to be good at it, might I recommend that you go out of your way during residency to:

get enough central lines to be comfortable putting one in all 3 locations within 5-10 minutes.
Get enough intubation practice to be comfortable with crash airways that are not optimal, and knowing when you should and shouldn't RSI airways.
Get practice splinting and suturing and wound care so those don't take you too long. Spending a few days with basic material in a fast track on days off should get you that.
Get ATLS certified (since you will be certified at least for PALS and neonatal resuscitations as med-peds) so you know how to handle a trauma.

You need ENT, ob-gyn, urology, and opthalmology experience too in terms of acute issues so you can handle those cases that come along. Most of the acute issues in these fields you will not encounter as Med-Peds.

Although ultrasound is a big part of EM nowadays, that is actually somethign you could get away without knowing how to do yourself. And if you changed yoru mind on that it doesnt' cost too much money to go to one of the many seminars out there.

That is much more useful information.


In reality, guys, I'm not planning to complete a med/peds residency and practice in the ED. I'll tell you that I'm either planning to complete and EM or a Med/Peds residency and practice in the respective field.... but my residual apprehension just has me wondering what the possibilities are if I made the wrong choice or if I change my mind. My new handle here allows some anonymity so you guys don't know which forum(s) I usually post in. In fact, I also posted for a buddy in the rads forums! I apologize if anybody is getting too bent over this thread.

 

[Apollyon]

I apologize if anybody is getting too bent over this thread.

Well, you certainly have the temper and breeding of med/peds - entirely civil, respectful, and polite. EM - "screw you! Tell me what I am asking! And get the hell on it right now!"

 

[AmoryBlaine]

It's possible to do this and you'd be a "meh" EM doc with several major deficiences for many years,
Now if you're ok being below average for many years, that's fine. But if you are going to do this route and want to be good at it, might I recommend that you go out of your way during residency to:

get enough central lines to be comfortable putting one in all 3 locations within 5-10 minutes.
Get enough intubation practice to be comfortable with crash airways that are not optimal, and knowing when you should and shouldn't RSI airways.
Get practice splinting and suturing and wound care so those don't take you too long. Spending a few days with basic material in a fast track on days off should get you that.
Get ATLS certified (since you will be certified at least for PALS and neonatal resuscitations as med-peds) so you know how to handle a trauma.

You need ENT, ob-gyn, urology, and opthalmology experience too in terms of acute issues so you can handle those cases that come along. Most of the acute issues in these fields you will not encounter as Med-Peds.

Although ultrasound is a big part of EM nowadays, that is actually somethign you could get away without knowing how to do yourself. And if you changed yoru mind on that it doesnt' cost too much money to go to one of the many seminars out there.

This is good advice and it shows how hard it will be to pull off the plan of doing Med/Peds and trying to work EM.

Here is the real reason: you are going to be comfortable with wheezing peds, vomiting babies, low risk chest pain, diverticulosis, vaginitis etc. But no matter where you do Med/Peds residency you will be s***ing your scrubs when the radio call says the medics are bringing in two gunshots, one of the to the chest and hypotensive.

You just won't be trained for it, and as a prior post stated very well this will wear on you hard and fast.

 

[Venko]

This is good advice and it shows how hard it will be to pull off the plan of doing Med/Peds and trying to work EM.

Here is the real reason: you are going to be comfortable with wheezing peds, vomiting babies, low risk chest pain, diverticulosis, vaginitis etc. But no matter where you do Med/Peds residency you will be s***ing your scrubs when the radio call says the medics are bringing in two gunshots, one of the to the chest and hypotensive.

You just won't be trained for it, and as a prior post stated very well this will wear on you hard and fast.

EM is way more than GSW...in fact the many centers will have trauma teams...so who cares then if he knows how to care for that patient. This is quite narrowly focusing what we do...and in fact that is probably the easiest thing we do in our specialty. Tube, Needle, Line....thank you cookbook medicine.

Dont sell our expertise in managing low risk chest pain. It is one of the most difficult things we do as far as making mental decisions. EMs approach to low risk chest pain is unlike anything trained in medicine, peds, cardiology, etc. I would argue that being formally trained to deal with undifferentiated chest pain, undifferentiated abdominal pain, undifferentiated headache are truly where the EM trained physician shines. Remember there is no "undifferentiated abdominal pain" team with stat team alpha (insert your trauma code here) overhead pages or ETA announcements to help you...its you, so you better be darn good! There is no American Abdominal Pain Life Support Algorithm to this or weekend AAPLS course to take. You get good by seeing patients, having great teachers, reading and thinking as an EM doc.

I'm sorry, I get worked up when others bring our specialty down to trauma (the simplest part of what we do), especially when people within EM do it. It implies that a trauma surgeon would then somehow be the uber EM doc, which is clearly false. They are distinct and both important specialties.

TL

 

[dchristismi]

I'm sorry, I get worked up when others bring our specialty down to trauma (the simplest part of what we do), especially when people within EM do it. It implies that a trauma surgeon would then somehow be the uber EM doc, which is clearly false. They are distinct and both important specialties.

TL

On that note... (a funny aside)

When I was a resident, the annual award banquet was the only night of the year that other residents covered the ED (so that all the EM residents were off.) It is usually a combination of IM and Gen Surg residents. At sign-out that night my second year, I happened to hear the trauma fellow (who would be running the bay that night in place of the EM chief) pick up the first chart in the rack... and promptly scowled, commenting that he had no clue where to start. It was a vag bleeder. We laughed, told him to wait for the knife and gun club and one of the IMs stepped up.

 

[AmoryBlaine]

EM is way more than GSW...in fact the many centers will have trauma teams...so who cares then if he knows how to care for that patient. This is quite narrowly focusing what we do...and in fact that is probably the easiest thing we do in our specialty. Tube, Needle, Line....thank you cookbook medicine.

Dont sell our expertise in managing low risk chest pain. It is one of the most difficult things we do as far as making mental decisions. EMs approach to low risk chest pain is unlike anything trained in medicine, peds, cardiology, etc. I would argue that being formally trained to deal with undifferentiated chest pain, undifferentiated abdominal pain, undifferentiated headache are truly where the EM trained physician shines. Remember there is no "undifferentiated abdominal pain" team with stat team alpha (insert your trauma code here) overhead pages or ETA announcements to help you...its you, so you better be darn good! There is no American Abdominal Pain Life Support Algorithm to this or weekend AAPLS course to take. You get good by seeing patients, having great teachers, reading and thinking as an EM doc.

I'm sorry, I get worked up when others bring our specialty down to trauma (the simplest part of what we do), especially when people within EM do it. It implies that a trauma surgeon would then somehow be the uber EM doc, which is clearly false. They are distinct and both important specialties.

TL

I wasn't trying to reduce it to trauma at all, merely saying that trauma would be an area where a medicine trained person would be particularly uncomfortable. It's very easy to see trauma as "cookbook" after you have dealt with 20-30 sick trauma patients. If you NEVER saw one in residency then you will load your pants.

I don't think undifferentiated complaints is much a specialty, I think resus and multi-tasking is. Undiff abdominal pain is usually labs and then deciding whether or not to CT while keeping dx in your mind that CT might not pick up i.e. early ischemia. I'm sorry but it's not that big of a deal. I think we give ourselves too much credit for our supposed judgement on these things.

EM docs don't show their stripes when the RNs room an undiff chest pain, AP, and headache all at the same time. We earn our stripes when they room all those people + a hypotensive trauma is coming in + there are already 2 patients on vents in the department.