Is EM fellowship a waste after FM residency?

[ddjamb]

Hi all, just wondering if the EM fellowship a waste for a FM trained candidate who wants to pick up shifts in ER.

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[deleted87716]

Probably. It's not a "real" fellowship (e.g., no CAQ), and most ERs that are desperate enough to hire an FP likely don't care if you're "fellowship trained" or not.

 

[Donchissy]

I know of an EM fellowship for FM graduates, and those FM trained EM fellows there would not even get hired to work in that same ER where they trained after graduating, He can only work in a smaller community hospital ER, and this is not a big city, this is a suburb/rural city of 90000 population.
If you are interesting in working in an urban setting, id say an FM trained EM fellowship is almost not worth it.
if you just want to do ER regardless of location, then there will be some smaller sized, possibly remote city that could be happy to have you

 

[ddjamb]

I know of an EM fellowship for FM graduates, and those FM trained EM fellows there would not even get hired to work in that same ER where they trained after graduating

that's embarrassing...

 

[Lexdiamondz]

Hi all, just wondering if the EM fellowship a waste for a FM trained candidate who wants to pick up shifts in ER.

Depends on what you want to get out of the fellowship. In general there are two main benefits to doing one:


1) Increasing your comfort level with working in the emergency department

2) Increasing your marketability for EM jobs


Truthfully speaking, the fellowship is probably more useful for making you a better ED doc than it is for getting you more ED jobs. It doesn't lead to board eligibility - probably the biggest drawback to doing one as jobs that require board-certified or board-eligible EM physicians still probably won't hire you.

 

[AMEHigh]

Are you currently in residency? Where do you want to work afterwards?

There are definitely places in which FM is still doing everything including EM, hospitalist, OB, etc. I think doing a fellowship would make one more comfortable with taking on that role and make you a better physician, but it likely won’t lead to more job options since many places now you have to be board eligible or certified to work in the ED. But if after you finish residency you’ll be in a location that hires FM for full spectrum care including EM then a fellowship can be helpful for your comfort level.

 

[Streetmath]

I know, at least, where I am currently living, most ER doctors in our few hospitals only completed a FM residency. In addition, most of the ER doctors are fairly "new". The reason, the best bang for your buck for a FM doctor here is in ER. Around 75 percent will only due a handful of ER shifts per month until the student debt is paid off and then, normally, will never work inside the ER again.

 

[MedicineZ0Z]

I know, at least, where I am currently living, most ER doctors in our few hospitals only completed a FM residency. In addition, most of the ER doctors are fairly "new". The reason, the best bang for your buck for a FM doctor here is in ER. Around 75 percent will only due a handful of ER shifts per month until the student debt is paid off and then, normally, will never work inside the ER again.

Canada is different.

 

[jm192]

I'm a hospitalist now. I was going down the pathway of hospitalist fellowships. And I talked to several of the fellowship directors. And one of the supposedly most notable ones was trying to give me the gig 2 years out. And that struck me as odd.

I live In Kentucky, and there were hospitals in some of the larger cities--though not Louisville or Lexington--that wouldn't talk to me because I was FM.

I ended up not doing the fellowship and the thing to highlight is all of those hospitals came calling when they had openings for long enough. The ER may be different. Maybe they won't take you not matter your experience/training. But that's been my life. Ultimately, the jobs offered substantially less than my current gig and I've declined them. Life is ironic enough that way.

As far as the programs themselves. There's really nothing that makes it official. You do it for a year or 2 and there's a piece of paper at the end. But it's not recognized by anyone. I'm not sure that it validates you anymore than a year of experience in general.

I was looking at a fellowship that was going to pay 80K. I was going to be working like a resident for another year. After talking with some other people, I did start to feel like it's a way for some hospitalist groups to get cheap labor. That's not to say their intentions aren't well. You may get excellent training.

And maybe that's an x-factor for someone. Maybe you don't feel comfortable going out on your own. I was really nervous about it. I took the leap and got paid a lot more. 2 Years into it, I don't regret foregoing the fellowship at all.

 

[MedicineZ0Z]

I'm a hospitalist now. I was going down the pathway of hospitalist fellowships. And I talked to several of the fellowship directors. And one of the supposedly most notable ones was trying to give me the gig 2 years out. And that struck me as odd.

I live In Kentucky, and there were hospitals in some of the larger cities--though not Louisville or Lexington--that wouldn't talk to me because I was FM.

I ended up not doing the fellowship and the thing to highlight is all of those hospitals came calling when they had openings for long enough. The ER may be different. Maybe they won't take you not matter your experience/training. But that's been my life. Ultimately, the jobs offered substantially less than my current gig and I've declined them. Life is ironic enough that way.

As far as the programs themselves. There's really nothing that makes it official. You do it for a year or 2 and there's a piece of paper at the end. But it's not recognized by anyone. I'm not sure that it validates you anymore than a year of experience in general.

I was looking at a fellowship that was going to pay 80K. I was going to be working like a resident for another year. After talking with some other people, I did start to feel like it's a way for some hospitalist groups to get cheap labor. That's not to say their intentions aren't well. You may get excellent training.

And maybe that's an x-factor for someone. Maybe you don't feel comfortable going out on your own. I was really nervous about it. I took the leap and got paid a lot more. 2 Years into it, I don't regret foregoing the fellowship at all.

Why exactly do these hospitalist fellowships exist except for cheap labor? Like what exactly does an fm residency not prepare you for when it comes to inpatient medicine? Unless you're doing open icu and procedures, in which case 2-3 icu rotations fix that problem.

 

[jm192]

Why exactly do these hospitalist fellowships exist except for cheap labor? Like what exactly does an fm residency not prepare you for when it comes to inpatient medicine? Unless you're doing open icu and procedures, in which case 2-3 icu rotations fix that problem.

That was a big part of what I was saying. I would assume the ER fellowships for FM are roughly the same. We had enough elective rotations that if your goal was to do ER, you could easily get ~6 months total in the ER. We also had to go to the ER twice a month as a second year resident.

I guess there's an argument that spending a year in an ER might increase your trauma exposure. But I think along the same lines of extra ICU rotations--you could spend time with surgery doing trauma cases

 

[VA Hopeful Dr]

That was a big part of what I was saying. I would assume the ER fellowships for FM are roughly the same. We had enough elective rotations that if your goal was to do ER, you could easily get ~6 months total in the ER. We also had to go to the ER twice a month as a second year resident.

I guess there's an argument that spending a year in an ER might increase your trauma exposure. But I think along the same lines of extra ICU rotations--you could spend time with surgery doing trauma cases

I think there could be value if the program you come from is light on inpatient/ED time since there is a good bit of variation from one program to the next.

 

[Kach]

I just finished my em fellowship and I agree with most of you. You don't really need the fellowship to negotiate higher pay or location of your job. A lot of that is determined by demand for docs and your ability to sell yourself. The real point of the fellowship is to become a better physician. It was definitely painful to give another year of my life away for training but the extra em skillset on top of my FM skills makes my job far more satisfying. Kind of funny to say this but I feel more like a doctor now.

 

[MedicineZ0Z]

I just finished my em fellowship and I agree with most of you. You don't really need the fellowship to negotiate higher pay or location of your job. A lot of that is determined by demand for docs and your ability to sell yourself. The real point of the fellowship is to become a better physician. It was definitely painful to give another year of my life away for training but the extra em skillset on top of my FM skills makes my job far more satisfying. Kind of funny to say this but I feel more like a doctor now.

what skills did you lack pre fellowship?

 

[Kach]

The best part of doing the fellowship is the skills that you learn. Number one -intubation and venous access. I've got 50 more Central lines and approximately the same number of EJ's under my belt now. I can perform intubation easily. Ever intubate a baby? I had to intubate two of em. Ortho - I can comfortably perform hip and shoulder Replacements under procedural sedation. I actuallyknow what drugs and doses to use. Ketofol combo. I'm comfortable with dental blocks, hematoma blocks. I actually know how to use a slit lamp machine!!! I can flick fb's off a cornea using and 18 gauge and can actually identify abrasions and hyphemas. I can't say enough about the ophtho skills alone. After some work on my IR rotation I can do a paracentesis fairly easily. Can't say the same for thoracentesis. Trauma - I performed several thoracostomies. Definitely didn't have the opportunity to do that during FM residency. I also feel way more confident during codes. In addition to normal acts algorithms I know when to use bicarb vs. Mag vs. Calcium. I had a patient that came in to my side ER job who was going in and out of sinus brady and and out of consciousness. I actually knew what to do for him! Slapped some transq pacers on him and flew him out. I would not have known to do that before this year. The point is I became more skilled. Could I have learned this wo the fellowship? Of course. Did this fellowship cost me half a mill in wages yes? Did I feel like a resident? Yes. Am I better skilled and knowledgeable doc because of the training? Definitely.

 

[Kach]

Joint reduction not replacement

 

[MedicineZ0Z]

The best part of doing the fellowship is the skills that you learn. Number one -intubation and venous access. I've got 50 more Central lines and approximately the same number of EJ's under my belt now. I can perform intubation easily. Ever intubate a baby? I had to intubate two of em. Ortho - I can comfortably perform hip and shoulder Replacements under procedural sedation. I actuallyknow what drugs and doses to use. Ketofol combo. I'm comfortable with dental blocks, hematoma blocks. I actually know how to use a slit lamp machine!!! I can flick fb's off a cornea using and 18 gauge and can actually identify abrasions and hyphemas. I can't say enough about the ophtho skills alone. After some work on my IR rotation I can do a paracentesis fairly easily. Can't say the same for thoracentesis. Trauma - I performed several thoracostomies. Definitely didn't have the opportunity to do that during FM residency. I also feel way more confident during codes. In addition to normal acts algorithms I know when to use bicarb vs. Mag vs. Calcium. I had a patient that came in to my side ER job who was going in and out of sinus brady and and out of consciousness. I actually knew what to do for him! Slapped some transq pacers on him and flew him out. I would not have known to do that before this year. The point is I became more skilled. Could I have learned this wo the fellowship? Of course. Did this fellowship cost me half a mill in wages yes? Did I feel like a resident? Yes. Am I better skilled and knowledgeable doc because of the training? Definitely.

What do you your fm residency lacked in terms of opportunities?

 

[Kach]

i didnt lack any opportunities.

 

[nimbus]

Am I missing something? Why not do EM residency if you want to work in ER?

 

[SterlingMaloryArcher]

Am I missing something? Why not do EM residency if you want to work in ER?

Yeah. The part where they didn't get into EM residency or decided late.

 

[deleted480308]

Am I missing something? Why not do EM residency if you want to work in ER?

Competitive. Not everyone can get in

 

[Lexdiamondz]

What do you your fm residency lacked in terms of opportunities?

LOL they literally gave a list of all the things they couldn't/didn't know how to do before doing a fellowship

 

[VA Hopeful Dr]

Competitive. Not everyone can get in

It's also not unusual to have a change in interest. My wife was dead set on going into a hemoc fellowship after residency. buy Christmas and for intern year she had decided against doing that because it no longer interested her, but general internal medicine did more so.

 

[VA Hopeful Dr]

LOL they literally gave a list of all the things they couldn't/didn't know how to do before doing a fellowship

my impression was that a fair number of those were things that the poster in question had done but not many. The third sentence even says 50 more Central lines.

 

[Lexdiamondz]

my impression was that a fair number of those were things that the poster in question had done but not many. The third sentence even says 50 more Central lines.

Not to be nitpicky but their tone makes it seem like they didn't know how to intubate, reduce joint dislocations, perform cardiac pacing, chest tubes or foreign body extraction/slit lamp exams before fellowship. They even said "I finally feel like a real doctor" (not to say that FM trained docs aren't real docs by any means).

 

[VA Hopeful Dr]

Not to be nitpicky but their tone makes it seem like they didn't know how to intubate, reduce joint dislocations, perform cardiac pacing, chest tubes or foreign body extraction/slit lamp exams before fellowship. They even said "I finally feel like a real doctor" (not to say that FM trained docs aren't real docs by any means).

I thought it was a mix of both, hence why I said it the way I did:

my impression was that a fair number of those were things that the poster in question had done but not many. The third sentence even says 50 more Central lines.

 

[MedicineZ0Z]

LOL they literally gave a list of all the things they couldn't/didn't know how to do before doing a fellowship

I said opportunities. Some fm residencies, both opposed/unopposed, may not provide adequate opportunity.

 

[Kach]

my impression was that a fair number of those were things that the poster in question had done but not many. The third sentence even says 50 more Central lines.

You're right, when I realized that I wanted to do em I tried to get as much experience as possible during fm res. So the fellowship gave me more time to accrue more experience.

 

[Kach]

Am I missing something? Why not do EM residency if you want to work in ER?

I'm a family physician just sharing my experience doing am em fellowship.

 

[Kach]

I said opportunities. Some fm residencies, both opposed/unopposed, may not provide adequate opportunity.

LOL they literally gave a list of all the things they couldn't/didn't know how to do before doing a fellowship

The post was not really meant to emphasize what I didn't know how to do, but to inform fm docs the types of skills you can obtain or enhance during a 1 yr fellowship.

 

[Kach]

Not to be nitpicky but their tone makes it seem like they didn't know how to intubate, reduce joint dislocations, perform cardiac pacing, chest tubes or foreign body extraction/slit lamp exams before fellowship. They even said "I finally feel like a real doctor" (not to say that FM trained docs aren't real docs by any means).

Fm residency taught me some of the skills. Some more thoroughly than others. Some less thoroughly.

 

[Kach]

Yeah. The part where they didn't get into EM residency or decided late.

The point of the post was to inform other fm's about an em fellowship experience not really to talk about em residency. All due respect to em grads and all of our many other specialist colleagues.

 

[Splenda88]

Why are people in EM so defensive about their specialty?

 

[Sardonix]

Why are people in EM so defensive about their specialty?

Because literally every specialty dumps on them for being a young specialty, or for being a jack of all trades master of none. I can't tell you the number of times I heard a highly specialized ortho/ENT/neuro complain about how the EM doc with full 16 beds at 3am didn't perfectly manage the patient EXACTLY the way they wanted.

Or in recent years everyone started complaining EM makes too much money. And now there are "No Surprise Billing" legislation in the works that might cut their income 20-50%.

I'm not EM, but I can see why they can get defensive.

 

[deleted87716]

And now there are "No Surprise Billing" legislation in the works that might cut their income 20-50%.

It's called "balance billing." Even being on the doctor side of this argument, I get why ER/hospital patients are pissed about this, as nobody gets to pick their ER doc or anesthesiologist, especially in an emergency. If their group happens to be out-of-network (by choice) with somebody's insurance (even though the hospital itself is in network), that shouldn't be the patient's problem.

 

[Sardonix]

It's called "balance billing." Even being on the doctor side of this argument, I get why ER/hospital patients are pissed about this, as nobody gets to pick their ER doc or anesthesiologist, especially in an emergency. If their group happens to be out-of-network (by choice) with somebody's insurance (even though the hospital itself is in network), that shouldn't be the patient's problem.

I tend to agree. I've seen some good EM counters to the recent proposed laws, but I have no dog in that fight for now. Just gotta say I can understand why EM docs may be walking around with hair-triggers regarding their field sometimes, though.

 

[deleted109597]

Why are people in EM so defensive about their specialty?

Same reason surgeons, anesthesiologists, pathologists, etc are. Except that other people can't do those, the hospital only doesn't seem to care about ER and ICU alone.
Are there enough EM boarded people? No. But there aren't enough surgeons either. There aren't enough primary care docs. Putting a warm body there just to fill a void isn't the best answer. It might be the only answer, but it isn't the best.
I support people increasing their education by doing this. If they're going to be working in an ER anyway, at least get some supervised experiential training.

 

[MedicineZ0Z]

Why are people in EM so defensive about their specialty?

Job market protection and I agree with them. But again, when some of the leaders in their field are fellowship trained family docs (on the Canadian side) who also function really well in the ED - it calls the competency factor into question.

 

[Splenda88]

Because literally every specialty dumps on them for being a young specialty, or for being a jack of all trades master of none. I can't tell you the number of times I heard a highly specialized ortho/ENT/neuro complain about how the EM doc with full 16 beds at 3am didn't perfectly manage the patient EXACTLY the way they wanted.

Or in recent years everyone started complaining EM makes too much money. And now there are "No Surprise Billing" legislation in the works that might cut their income 20-50%.

I'm not EM, but I can see why they can get defensive.

Some of these docs have nice gigs. One of them shared with me the other day that he works only 10 8hr shifts per month and still make 250k/year with benefits. This is crazy! But these people deserve every penny they make because their job is not easy.

I agree that physicians in other specialties do not like them. I was kind of perplexed when I started residency to see other physicians (mostly IM and its subspecialties) criticize them in front of other ancillary staffs.

 

[Lexdiamondz]

Some of these docs have nice gigs. One of them shared with me the other day that he works only 10 8hr shifts per month and still make 250k/year with benefits. This is crazy! But these people deserve every penny they make because their job is not easy.

I agree that physicians in other specialties do not like them. I was kind of perplexed when I started residency to see other physicians (mostly IM and its subspecialties) criticize them in front of other ancillary staffs.

I find that the people who dump on the ED the most are people from specialties that don't rotate in EM as part of their training or physicians so old they trained before EM was a specialty. In general there's a poor understanding amongst medicine as a whole of what EM is and what the ED is for which leads to these conflicts.

Job market protection and I agree with them. But again, when some of the leaders in their field are fellowship trained family docs (on the Canadian side) who also function really well in the ED - it calls the competency factor into question.

Yes and no. Again - EM was founded by non-EM trained people and there are plenty of competent FM trained docs in EM. That being said, the variance in competence is (anecdotally) far higher among non-EM trained physicians IMO. In 2019 many of those same FM trained pioneers would say categorically that there is no non-inferior substitute for EM residency.

Furthermore, having a handful of leaders in the field from other training pathways doesn't invalidate the value of the EM residency as the gold standard, nor does it validate a 1 year fellowship as an acceptably good alternative. Amal Mattu is extensively published in Cardiology but he's not a cardiologist - does his work invalidate the need for a cards fellowship? No. Swami is extensively involved in critical care in the ED but does that invalidate the need for an ICU fellowship? No.

 

[VA Hopeful Dr]

I find that the people who dump on the ED the most are people from specialties that don't rotate in EM as part of their training or physicians so old they trained before EM was a specialty. In general there's a poor understanding amongst medicine as a whole of what EM is and what the ED is for which leads to these conflicts.

I'm not convinced that's true, or at least not the reason for the vast majority.

Reasons I've seen that people dislike the ED:

-Y'all give them work, often of the uncompensated variety (whether uninsured patients on straight salaried doctors - I've noticed that the ED doctors in locations that pay based on productivity don't have nearly the trouble that salaried places do). I think this is the primary reason.

-You don't do things exactly as they want them done. Doctors are prima donnas, we all know it.

-Like any other specialty, some of your doctors suck. I was very anti-EM for awhile because of one asshat who called and berated me with every patient I sent to him, including a proven bowel obstruction that had surgery the next day.

 

[betamale]

I don't mind those dumps. Keeps me employed and my numbers (pph) looking good

 

[MedicineZ0Z]

Yes and no. Again - EM was founded by non-EM trained people and there are plenty of competent FM trained docs in EM. That being said, the variance in competence is (anecdotally) far higher among non-EM trained physicians IMO. In 2019 many of those same FM trained pioneers would say categorically that there is no non-inferior substitute for EM residency.

Furthermore, having a handful of leaders in the field from other training pathways doesn't invalidate the value of the EM residency as the gold standard, nor does it validate a 1 year fellowship as an acceptably good alternative. Amal Mattu is extensively published in Cardiology but he's not a cardiologist - does his work invalidate the need for a cards fellowship? No. Swami is extensively involved in critical care in the ED but does that invalidate the need for an ICU fellowship? No.

I dont disagree with any of this so there's no debate really.

 

[moonwake]

Just chiming in as a 4th year (hopefully) soon to be FM intern. My prospective program only has 2-3 months of EM (very heavy OB program). If I was planning on doing any ER shifts after I would feel completely inadequate even if I did my 6m of electives (I know it would be in the middle of nowhere at some desperate hospital). It makes sense why a fellowship exists... possibly for grads of this program or similar so they at least have a minimum competency of managing ER patients (unless you believe your program gives you that). Still gives me the creeps that some 2nd year residents manage ERs out in small towns though. I can't imagine having had more than a few months of ER experience?

 

[linguistafeliz]

To moonwake... in my opinion, these rural hospitals have a lot of trouble recruiting physicians. Also, at my program, 2nd year residents typically moonlighted in a nearby urgent care (where they have plenty of support and help w/ decision making as they got their feet wet) and waited until 3rd year to moonlight at rural ERs. These ERs may be choosing between hiring 3rd year residents or midlevel providers and having to close. Even though these residents may have only have had 2 months of ER experience, they have also had 2+ years of intensive OB and inpatient training which IMO helps prepare them for their time in a rural ER.

All of this being said, in my opinion EM residency is hands-down the best option for physicians who know they want to practice primarily in an ER setting.

 

[quicksilverdo]

The US needs to adopt the Canadian EM system.

 

[MedicineZ0Z]

Just chiming in as a 4th year (hopefully) soon to be FM intern. My prospective program only has 2-3 months of EM (very heavy OB program). If I was planning on doing any ER shifts after I would feel completely inadequate even if I did my 6m of electives (I know it would be in the middle of nowhere at some desperate hospital). It makes sense why a fellowship exists... possibly for grads of this program or similar so they at least have a minimum competency of managing ER patients (unless you believe your program gives you that). Still gives me the creeps that some 2nd year residents manage ERs out in small towns though. I can't imagine having had more than a few months of ER experience?

I'd argue for those people that their ICU/anesthesia experience ends up being more useful in rural settings (than just ER experience) where you have critically ill patients at a lower frequency + more time to figure things out.

 

[deleted87716]

The US needs to adopt the Canadian EM system.

The US doesn't need anything that Canada has.

 

[MedicineZ0Z]

The US doesn't need anything that Canada has.

It outperforms USA in only like... everything. That is if you can put aside (pure) subjective bias.

 

[deleted480308]

It outperforms USA in only like... everything. That is if you can put aside (pure) subjective bias.

except it doesn't