Newbie question- what role do Family Medicine doc's have when working in the ER?

[globalism]

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Hi,

I don't quite understand in what fashion family medicine docs practice in emergency rooms? What's their role? Do they work in ER's in underserved areas (and thus are the ER docs there) or do they work side-by-side EM doc's in ER's in some other role?

Also, are the salaries of FM doc's working in ER's a little greater than what's typical (for FP's)?

I'm a newbie and thinking about going into FM. Thanks.

 

[erichaj]

Answer:

What role does any doctor have in the ER when they see a pt?

To evaluate and treat or send to appropriate specialty. Like surgeon or GI etc.

Just Like the ER doctor.

EH.

 

[globalism]

Answer:

What role does any doctor have in the ER when they see a pt?

To evaluate and treat or send to appropriate specialty. Like surgeon or GI etc.

Just Like the ER doctor.

EH.

Are the salaries and work schedules (of FM docs working in the ER) similar to that of EM docs working in an ER? More specifics please, thanks.

 

[emtp2pac]

typically fp docs working in er's are in smaller, lower volume, and/or rural facilities that can not afford an er doc. because the volumes are lower the shifts are typically single coverage 12 or 24 hr shifts as opposed to the shorter shifts seen at busier facilities.the er's in this area that use fp docs pay them $60-8o/hr while a residency trained/boarded er doc can often get $100-150/hr. if you are thinking about D.O. there are a few(5) dual em/fp residencies that take 5 yrs to complete.there are a few fp fellowships in em but they do not lead to board certification by the same board as em docs, but can get you in the door for those rural/low volume er's that typically want a few yrs of experience in em. good luck whatever you decide. see the fellowship page at www.aafp.org for info

 

[globalism]

typically fp docs working in er's are in smaller, lower volume, and/or rural facilities that can not afford an er doc. because the volumes are lower the shifts are typically single coverage 12 or 24 hr shifts as opposed to the shorter shifts seen at busier facilities.the er's in this area that use fp docs pay them $60-8o/hr while a residency trained/boarded er doc can often get $100-150/hr. if you are thinking about D.O. there are a few(5) dual em/fp residencies that take 5 yrs to complete.there are a few fp fellowships in em but they do not lead to board certification by the same board as em docs, but can get you in the door for those rural/low volume er's that typically want a few yrs of experience in em. good luck whatever you decide. see the fellowship page at www.aafp.org for info

Thanks for the useful information.

 

[gherelin]

Interestingly, although true or not I have no idea, an older "seasoned"ER Doc formerly an FP Program Director, told me that originally, prior to EM being its' own specialty, an attempt was made to have a fellowship in EM after completion of FP residency, much like other fellowships after IM but that the FP powers-that-be rejected the proposal. If true, bad move.

 

[erichaj]

aHHHHHHHHH,

You did not ask about salaries. So, what you want to know is:

Can you go to FP and work in the ER and bypass the ER residency so you can have you options open.

OK, now that we have the facts.

No, ER docs make more money to start with but if you are a seasoned FP in the ER you can match the income.

Good Luck.

EH.

 

[DrQuinn]

Be aware that you can now currently work in some low volume ED's as a primary care physician, but in the future, most if not all hospitals will shift towards "BCEM" being the standard of care in the Emergency Department. If you truly love Emergency Medicine, just do the EM residency. Even if you want to occasionally do some outpatient, you can easily work in urgent care centers or pull a few shifts in your friend's FP practice seeing only walk-ins.

The door will be shut (fortunately or unfortunately) for those training in FP programs now who think they will be able to work in the ED the rest of their career.

Q

 

[dr.smurf]

i dont think many people go into fp with the intentions of doing er for life. i for one want to do both...some er shifts/urgent care and part-time outpt office. quinn is right in the sense that it will be harder for fps to enter the er. with the healthcare crisis we are in now with litigation, insurance co's, and politics running medicine things that flew in the past wont be flying so high anymore. but, there will always be some role for fps in the er...primarily rural areas. the latest study ive seen indicates that there will be a shortage of er docs until 2020 as the specialty is fairly new as compared to others. im sure the various boards will come to some agreement on combining programs like fp/em, etc. i cant see why not.

 

[emtp2pac]

as a d.o. it is already possible to do an em/fp residency in 5 yrs leading to dual board certification. only 5 programs though and none on the west coast.....

 

[LukeWhite]

I'd agree that FP days in the ER are numbered *if* current health care trends continue as they have. But is this really likely? I see a few inevitable developments that would seem to make the ER-doc fantasy of 100% board certification tough:

--Decreased litigation/malpractice insurance. This sort of legislation is very popular, and it's only a matter of time before malpractice is capped. Depending on who wins the Presidency, this could start shifting things within a few years.

--Increased usage of ER for primary care-related complaints. Ah, this is the big one. ER docs certainly have differing opinions on this, but the sense I get is that they feel qualified to at least triage these folks, but don't want FP treading on their territory. Given ER volumes, though, it's going to be tough to find enough docs to staff these places, particularly in rural areas. Perhaps in the truly needy towns that have closed down their ERs we'll call them urgent care clinics instead, but the work and pay will surely be similar to what FPs do now when they're in understaffed ERs.

Dangerous to extrapolate a straight line outward, particularly from what ER docs *want* as opposed to what they'll *get*. I think there are some shifts in store.

 

[DrQuinn]

--Increased usage of ER for primary care-related complaints. Ah, this is the big one. ER docs certainly have differing opinions on this, but the sense I get is that they feel qualified to at least triage these folks, but don't want FP treading on their territory. Given ER volumes, though, it's going to be tough to find enough docs to staff these places, particularly in rural areas. Perhaps in the truly needy towns that have closed down their ERs we'll call them urgent care clinics instead, but the work and pay will surely be similar to what FPs do now when they're in understaffed ERs.

Dangerous to extrapolate a straight line outward, particularly from what ER docs *want* as opposed to what they'll *get*. I think there are some shifts in store.

I agree that the increased usage of the ED is a big problem. Even though there are increasing patient visits to the ED, and perhaps more "non emergency visits," there will always be trauma alerts, MVAs, stabbings, MIs, etc. I have no problem whatsoever with an FP running the "fast track" to handle all the med refills, back pain, sore throats that they want.

Q

 

[dr_almondjoy_do]

I agree that the increased usage of the ED is a big problem. Even though there are increasing patient visits to the ED, and perhaps more "non emergency visits," there will always be trauma alerts, MVAs, stabbings, MIs, etc. I have no problem whatsoever with an FP running the "fast track" to handle all the med refills, back pain, sore throats that they want.

Q

P.A.s do that in NY. They run the whole fast track and assist in triage while being overseen by an ER doc. No RNs, just MD/DO and PAs. The P.A.s start @ 100K out in Long Island to work 3, 12hr shifts. I know b/c a friend of mine that graduated from PA school last year is making 100K starting salary.....

I would only imagine what the ER doc gets...

 

[bigdreamer#1]

as a d.o. it is already possible to do an em/fp residency in 5 yrs leading to dual board certification. only 5 programs though and none on the west coast.....

Where can I find this information about these programs? I am in an osteopathic medical school, and may be interested?

Thanks!

 

[Freeeedom!]

Some of the groups in my area do not hire PA s or NPs anymore and hire only FP doctors to work the fast track.
I think we have had so many problems with the NP's lack of education that it had to change, and the FP's seem to solve the problem.
The other solution were moonlighters.

 

[deleted6669]

info on all do em residencies at www.acoep.org
good luck
I know that pontiac in michigan, st barnabas in nyc, and a few others still have this em/fp option

 

[kungfufishing]

" Dangerous to extrapolate a straight line outward, particularly from what ER docs *want* as opposed to what they'll *get*. I think there are some shifts in store."[/I]

Doesnt much of the drive for hiring BCEM physicians originate from healthcare organizations? Your post suggests that the EPs are trying to corner the EM market, which I think misses the point that a residency trained Physician will do the best job. Hence, EM the specialty.

A residency trained doc SHOULD get the ED job over someone who trained in another specialty because this is what he/she is trained to do, and vice versa. FPs can have the continuity, checkups, chronic management, and relationships - I wont be qualified to handle much of what they do and dont want to be. In rural areas, Im sure there will always be spots for FPs, and in fast track/urgent care settings as well. However, regardless of overutilization a busy urban ED isnt just a big clinic, and there is a reason that the sign says "emergency" on it.

The point that EM is a specialty, not a side job or a career diversion away from what a physician originally trained in, has been made numerous times on this forum (and by hospitals, accreditation organizations, lawsuits...).

 

[LukeWhite]

I certainly won't disagree that an ER doc does a sight better in the ER than a family practice doc. That doesn't matter, though, if there aren't enough ER docs to fill the slots. Until then, every ER grad will be hired, and the gap's going to have to be filled in some other fashion.

The two viable options that I see are fewer emergency departments and increased hiring of family practice docs. Liability's led to a bit of the former, particularly in doubly-or-triply-covered urban areas and very low traffic rural areas, but at some point the harm in having too few departments and docs begins to outweigh the harm that a FP doc might do moonlighting.

So again, it's not a matter of family practice docs getting jobs over ER docs, as you seem to imply--I doubt that happens in all but a few instances, and no ER docs are going hungry. There simply aren't enough, though, and it doesn't seem to me that residency training is going to catch up with the nation's emergency med needs anytime soon.

So it ends up being a question of who's best suited to fill the gap, and FP is in a good position to answer that. Great procedure-oriented, broad scope of practice residencies like Ventura, Tacoma, etc are turning out doctors who can certainly hold their own in the ER even if not as well trained as they would have been in an ER residency. It's not a matter of competition or encroaching on ER docs' territory; it's a matter of filling a need, and there's plenty to go around.

 

[DrQuinn]

Everyone talks about how rural EDs can't afford to pay ABEM certified physicians... but talkign to my attendings, they said they could actually get paid more if they worked in EDs in "bum-fudge." Granted, we're not talking about the 20 bed hospitals, but the ~100 bed hospitals with a 5-10 bed ED. I know lots of ED grads who are taking those jobs and making 200k+ working 32-36 hours a week. I am not hearing about how these EDs are not getting filled with EM trained grads. In fact, I would be willing to commute out to work in that setting when I graduate. I don't necessarily have to work in the Level I 70k+ ED I am training at now, even though its a great place to train.

Q

 

[LukeWhite]

But Quinn, wouldn't you agree that every emergency med grad gets a job without too much effort? If this is true, and FP docs are still doing a lot of work in the ER, then there's a gap between staffing needs and what ER residencies can provide.

So if all that's true, the only question is whether that gap's going to be closed or not. It seems pretty unlikely to me...the impression I get is that ER volume is at its nadir with so many recent closings, and there's going to be a whole lot more traffic as the population grows and ages. It would be great to have enough ER docs to fill the void, and since plenty of other specialties are glutted, some reapportionment is in order. This just doesn't seem likely, though. Better, then, to run FP programs with an eye to at least some competence in ER med than not to, and have them fill the gap unprepared.

 

[Seaglass]

Luke that certainly is true, I think it's just that we cannot recommend a student going into FP with the main goal of working in the ED. Sooner or later, and most likely for liability reasons, FPs are going to be pushed out of the ED until such time as the malpractice situation is more reasonable. I think the demand really has little to do with it as people in this country have already decided that the need for medical care does not obligate society to provide it.

 

[LukeWhite]

I agree that it would be unwise for someone to attempt FP as a sort of backdoor to EM. Personally, I don't think that will be an issue anytime soon--if ER residencies expand to match demand, competitiveness will decline. If they don't expand sufficiently, FP docs will still have a crucial role at least in non-urban ED's.

Regarding liability, I'm persuaded by the argument as far as the metro borders extend. There should be enough resources in an urban area to have a few highly efficient EDs fully staffed by people who know their way around.

In rural and even small-city environments, I'm just not sure that liability's so great a factor that it's going to force FP docs out anytime soon. As far as liability goes, obstetrics is a couple decades ahead of emergency med. in terms of getting itself into a pretty nasty mess, and while the number of FP docs in the field has certainly declined, they've hardly been eradicated in favor of bc'd OB/GYNs. The reason's the same as for EM--someone's got to do it, and until such time as we've got enough specialists in those fields, family med will fill in the gap. I suppose that emergency med liability could get as bad as obstetrics, but this seems unlikely to me given that OB is pretty much at a nadir of effectiveness right now; a similar lack of efficiency in EM couldn't happen before an Outraged Nation Made Reforms.

So I suppose we'll see, but from everything I've seen, the future of well-trained FP docs from unopposed residencies in rural and small-town ERs looks stable, if not sunny.

 

[Seaglass]

and while the number of FP docs in the field has certainly declined, they've hardly been eradicated in favor of bc'd OB/GYNs.

You've got to be kidding. When I wanted to do my FP rotation in Pennsylvania with people who delivered they couldn't find any. The FPs I knew in PA didn't know any others who still did OB.

 

[LukeWhite]

You've got to be kidding. When I wanted to do my FP rotation in Pennsylvania with people who delivered they couldn't find any. The FPs I knew in PA didn't know any others who still did OB.

East coast phenomenon, likely secondary to that whole big city thing. FPs do a *lot* of OB out west, and not just the simple, uncomplicated delivery. Ventura runs most of its residents through about 30 C-sections as primary surgeon. The job ads on the west coast are far more likely to advertise looking for an FP doc with OB experience and the training to get pretty extensive hospital privileges.

But I'll agree that a FP doc out east is a different breed. I wouldn't want an FP doc who'd done a residency east of Ohio doing any sort of surgery on me or seeing me in the ER for anything but triage and sutures, but I'd trust a good California/Washington/Idaho FP with that and more.

 

[DrQuinn]

I wouldn't want an FP doc who'd done a residency east of Ohio doing any sort of surgery on me or seeing me in the ER for anything but triage and sutures, but I'd trust a good California/Washington/Idaho FP with that and more.

I wouldn't want any non surgeon doing any sort of non local surgery on me.

I havent' met an FP who did any form of OB.

I have no problem with people who are doing FP *try* to pursue EM. As long they understand the caveat that in the next X number of years (far sooner than later) their job will be in jeopardy.

One of my fellow residents (a pgy2) was a Med/Peds attending who worked in the ED. He saw a LOT of non BCEM physicians who worked in the ED get canned... a lot of the hospitals in the CMG he worked for was lopping them off like gangrenous toes. That's why he went back to get BC'd. I wish I could get him to post on SDN, he'd tell some horror stories about PCP working in the ED.

Q

 

[LukeWhite]

Re. FP/OB, I'm increasingly convinced it's a coastal phenomenon. Back in the Midwest, FPs doing OB aren't as common as on the West coast, but neither are they freaks of nature. On the west coast, though, there are *plenty* of FPs who are highly competent in OB. Some of this is malpractice, some the cultural makeup of medicine. A lot of it is due to the fact that people in general, including OBs prefer in aggregate to live in places like Tampa and Winston-Salem to Washington State and Alaska.

 

[BellKicker]

FP/OB.........

I guess it depends on where you're looking. In the rural midwest, FPs deliver most of the low-risk pregnancies. All my kids cousins were delivered by FPs. I mean, the smaller hospitals are run by FPs. I guess people could go to a midwife but other than that, it's all FPs.

Of the 9 FP programs I'll be interviewing with, only one doesn't emphasize OB. The last one has OB available as a special track. Again, this is the upper midwest and most of these programs are unopposed. I have no idea what it's like anywhere else.

On a side note, over here (Denmark) an FP hasn't delievered a baby in many years. Oftentimes, Scandinavia is a picture of what America will look like in 10 years so maybe that's one indicator to look at.

 

[Willamette]

You've got to be kidding. When I wanted to do my FP rotation in Pennsylvania with people who delivered they couldn't find any. The FPs I knew in PA didn't know any others who still did OB.

They must not have looked too hard, as I know of at least three FPs in Pennsylvania that do OB...and one of them even does C-sections. Not that three's a bunch, it's just that I'm not from around here, haven't particularly looked into PA FP's who do OB, and I still can name a few.


Willamette

 

[FoughtFyr]

BUMP - as a reply to another thread.

- H