Opportunities for EM docs in primary care

[lacesoutdan]

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I’m an M3 and I think I want to become an EM doc. I’m pretty much sold on the specialty, with my one big concern being that I won’t want to work a lot of overnights when I get old. A combined EM/FM residency is probably out of the question for me because I see a 3 year residency as a major selling point for EM. So I have a few questions about possibly scaling back my hours in the ED later in my career:

1. Is possible/legal for me to open my own or join a family practice if I did an EM residency? After rotating through family medicine, it is my opinion that I will be more than capable of managing peoples’ primary care after an EM residency even if that’s not what the residency was designed for. Basically if I get old and decide I don't want to do EM anymore, can I bail to FM because I want no night shifts and less stress?

2. Is it possible to become board certified in FM if you did a residency in EM? Like can I just pass the board exam and become family board certified?

3. I rotated with a family doc who did a sports medicine fellowship and now runs the student health clinic at a university and is a primary care team doc for the school’s teams. Lets say I do an EM residency and then sports medicine fellowship. Is it possible for me to do the same thing as that guy down the road?

4. Has anyone ever heard of an EM doc working a couple ED shifts a week and then having their own primary care sports medicine clinic at the same hospital, which they have like maybe one day per week?

Thanks in advance for any insight you guys can give me into your wonderful field.

 

[Apollyon]

Family medicine is its own training and residency, and board certification. The only path to board certification for ABMS specialties to do a residency in that field. What you ask is called "grandfathering", which occurs in new specialties that do not have enough practitioners yet to require training in it. One unrecognized specialty that is pursuing recognition by ABMS is "The American Board of Addiction Medicine". By taking their certification exam, one can become certified based on experience; if they achieve ABMS recognition, doing a residency in addiction medicine would then be the only way to become board-eligible.

EM graduates can do sports medicine fellowships. One of the attendings from when I was a resident did a fellowship in sports medicine while I was there, and now he has dual appointments in EM and Sports Med, with one or two clinic days per week.

As you "get old" and don't want to do nights anymore, instead of doing family medicine (which isn't something into which you can just slide), you could consider urgent care - there's a lot of overlap between FM and EM, but they are not the same. In urgent care, though, they dovetail nicely.

 

[gutonc]

On a slightly less helpful and snarkier note, the inverse of this question (can I do a residency in FM and practice in the ED?) gets asked here about once a week.

Advanced Search is your friend.

 

[Patel1268]

Or you could do a FM and moonlight as an ER doc until you are into the later years of your career. But I think as time goes on...more ER's (especially in bigger institutions) are employing more/olny certified EM docs. This is different from community medicine though from what I hear.

 

[docB]

I give you the same answer I give when people ask if other specialties can work in the ER: You probably can, but you really shouldn't.

If you're truly committed to EM and you're worried about how to wind down your career then I suggest you consider some of the many options EM provides without trespassing into someone's else's specialty that you aren't trained for.

-Work fewer shifts. A simple and readily doable option in almost any group. You'll make less but presumably you will need less at that time in your career (remember that you'd make less bootlegging primary care too.)

-Switch to lower volume EDs. Again less money but less stress and wear and tear with the occasional disaster to keep you on your toes.

-Urgent care. I personally wouldn't want to work a fast track all day but it's definitely an option. Also, why are so many people using urgent cares for primary care? Who are these guys who are managing htn and dm in urgent care settings with haphazard continuity? Oh well. A discussion for another time.

-Work only double covered shifts. In some groups you can choose to (or be forced to, that's another story) work only double covered shifts so it's harder to get destroyed.

 

[DeadCactus]

On a slightly different note, but to avoid making an entirely new thread, are there options to slightly increase the continuity of care an EP has with his patients?

I'm not concerned with following a patient for life, but I think I'd really enjoy the sort of intermediate level of continuity where you see them through the resolution of their current hospitalization.

Is there a viable option for that?

 

[Powdermonkey]

On a slightly different note, but to avoid making an entirely new thread, are there options to slightly increase the continuity of care an EP has with his patients?

I'm not concerned with following a patient for life, but I think I'd really enjoy the sort of intermediate level of continuity where you see them through the resolution of their current hospitalization.

Is there a viable option for that?

Internal Medicine.

 

[docB]

On a slightly different note, but to avoid making an entirely new thread, are there options to slightly increase the continuity of care an EP has with his patients?

I'm not concerned with following a patient for life, but I think I'd really enjoy the sort of intermediate level of continuity where you see them through the resolution of their current hospitalization.

Is there a viable option for that?

I think the closest to that would be to do the critical care route and then set yourself up to do several months of CC per year. Then you would follow patients throughout their ICU stays. Now in that case you wouldn't be the EP starting them out.

The other option is to be vigilant in your follow up of your patients. I frequently try to follow up with admitting docs about pt's courses.

Neither of those really amount to seeing an ED patient and then following them through but as far as I know that situation is very rare.

 

[taylormade2006]

I think the closest to that would be to do the critical care route and then set yourself up to do several months of CC per year. Then you would follow patients throughout their ICU stays. Now in that case you wouldn't be the EP starting them out.

The other option is to be vigilant in your follow up of your patients. I frequently try to follow up with admitting docs about pt's courses.

Neither of those really amount to seeing an ED patient and then following them through but as far as I know that situation is very rare.

docB, are you following the conversation about HIPAA in the general residency forum? How does this scenario relate to that conversation?

 

[docB]

docB, are you following the conversation about HIPAA in the general residency forum? How does this scenario relate to that conversation?

I think that getting follow up information about a patient I have treated fits within HIPAA. My understanding is that it generally does not want to restrict clinicians from sharing clinical information. I could be wrong. As is usually the case with healthcare related regulation no one knows who's wrong until someone gets dinged.

 

[DeadCactus]

Yea, my thoughts were that my options basically come down to EM/CC, EM/IM, or EM/Peds if I want to be an EP but still have a portion of my practice involve more continued care. I suppose there's also the Peds/Ped EM route if I can give up seeing adult patients.

I just wanted to make sure I wasn't missing any options...

 

[AmoryBlaine]

Yea, my thoughts were that my options basically come down to EM/CC, EM/IM, or EM/Peds if I want to be an EP but still have a portion of my practice involve more continued care. I suppose there's also the Peds/Ped EM route if I can give up seeing adult patients.

I just wanted to make sure I wasn't missing any options...

If you're worried about doing shift work for your career and want continuity I would say don't go into EM.

The question is not "can I do this" but "do most people do this," when the answer is no that usually means it's either really hard or really unsuited to the personality of EM.

That said, continuity is vastly over-rated.

 

[Apollyon]

That said, continuity is vastly over-rated.

Disagree. On the occasion there is something interesting, I like to hear how are going or went. That doesn't mean I'm overjoyed to see the same frequent fliers, but "womb to tomb" is just as positive for some people, which is why they do other specialties, as it is antithetical to us.

Two weeks back, had a code come in. EMS said initial rhythm was asystole, but they got a pulse back, but couldn't tube the patient. I figured it would be a bloody mess, so I called for the critical care doc and the GlideScope (they just won't bring it down). It was a bloody mess, and the CCM doc got the tube in, and took over (which I later found out was prone to his personality). He said, "We'll give her 1 more epi, and, if nothing, we'll call it." She got her epi - and a pulse! (Ha ha, sucker, I thought.) However, no response to any stimuli, at all. Talked to one of the docs 5 days later, who said she's still alive, and zero motor function.

 

[dchristismi]

A degree of follow up was required in my residency program, and as treating physician, that should be covered under HIPAA (My understanding being similar to DocB's). I regularly have my follow-up nurse check on transfers, and often call up to the ICUs to see how some of the sickies are doing.

I had a lady 2 nights ago crash and burn on me - ended up on a vent after having what I presumed was a big MI with +trop and no ekg changes. But turns out she had clean coronaries and an unusual congenital malformation - she didn't have a left main. So it was a cardiomyopathy that cards is still sorting out. But I wondered how she did, and was very glad to hear that she's doing fairly well.

Same goes for a code I ran the other night on an ICU patient who I had pretty much given up for dead (sepsis/CRRT). It was a VF arrest with some torsades (sort of unusual for ICU) - the guy is now awake, extubated, off pressors and was asking for donuts per the ICU nurse. Crazy.

Some of that kind of follow up is good - knowing that you did something right is just as important as knowing you did something wrong, and we don't usually get the positive feedback. But that doesn't mean that I look forward to seeing the same migraneur every week.

 

[txterp98]

I'm not concerned with following a patient for life, but I think I'd really enjoy the sort of intermediate level of continuity where you see them through the resolution of their current hospitalization.

Is there a viable option for that?

Have you considered IM and then becoming a hospitalist? No, they don't do the initial evaluation, but they do end up seeing the patient in the ER, following them through their hospital stay, and discharging them at the end.

Is this the sort of intermediate level of continuity you might be hoping for?

 

[Birdstrike]

I used to think the combined primary care/ EM residencies were a waste of time. I no longer think that. I know many ER docs 5-10+ years out that, looking forward, would love the option of being double boarded in something that offers a pathway out of the nights/days/nights/days/weekends/holidays grind of full time EM towards the 2nd half of their careers, myself included. Although the extra training may seem painful, it's a great option to have later on, should you need it.

 

[Residual]

I used to think the combined primary care/ EM residencies were a waste of time. I no longer think that. I know many ER docs 5-10+ years out that, looking forward, would love the option of being double boarded in something that offers a pathway out of the nights/days/nights/days/weekends/holidays grind of full time EM towards the 2nd half of their careers, myself included. Although the extra training may seem painful, it's a great option to have later on, should you need it.

Even with a double residency, though, is it really viable to do full EM for 10-20 years and then just switch into something like FM after being out of it that long?

 

[Birdstrike]

Even with a double residency, though, is it really viable to do full EM for 10-20 years and then just switch into something like FM after being out of it that long?

A lot more viable than if you don't have the 2nd board. Ideally you'd do a mixture along the way, whether it be 50/50, 80/20, 20/80, etc. Also, you'd be doing CME along the way and having to study for boards, etc.

 

[MJB]

Disagree. On the occasion there is something interesting, I like to hear how are going or went. That doesn't mean I'm overjoyed to see the same frequent fliers, but "womb to tomb" is just as positive for some people, which is why they do other specialties, as it is antithetical to us.

Two weeks back, had a code come in. EMS said initial rhythm was asystole, but they got a pulse back, but couldn't tube the patient. I figured it would be a bloody mess, so I called for the critical care doc and the GlideScope (they just won't bring it down). It was a bloody mess, and the CCM doc got the tube in, and took over (which I later found out was prone to his personality). He said, "We'll give her 1 more epi, and, if nothing, we'll call it." She got her epi - and a pulse! (Ha ha, sucker, I thought.) However, no response to any stimuli, at all. Talked to one of the docs 5 days later, who said she's still alive, and zero motor function.

Poor woman.

 

[DeadCactus]

Have you considered IM and then becoming a hospitalist? No, they don't do the initial evaluation, but they do end up seeing the patient in the ER, following them through their hospital stay, and discharging them at the end.

Is this the sort of intermediate level of continuity you might be hoping for?

I've considered it, but I don't think lack of continuity would be a deal breaker for me. I was just curious if there is a route to add it in to an EM practice as a bonus. A lot of other specialties have something that I think I would really enjoy, but EM seems to be the only specialty that really covers all of the things I consider the most important...

 

[AmoryBlaine]

Disagree. On the occasion there is something interesting, I like to hear how are going or went. That doesn't mean I'm overjoyed to see the same frequent fliers, but "womb to tomb" is just as positive for some people, which is why they do other specialties, as it is antithetical to us.

Two weeks back, had a code come in. EMS said initial rhythm was asystole, but they got a pulse back, but couldn't tube the patient. I figured it would be a bloody mess, so I called for the critical care doc and the GlideScope (they just won't bring it down). It was a bloody mess, and the CCM doc got the tube in, and took over (which I later found out was prone to his personality). He said, "We'll give her 1 more epi, and, if nothing, we'll call it." She got her epi - and a pulse! (Ha ha, sucker, I thought.) However, no response to any stimuli, at all. Talked to one of the docs 5 days later, who said she's still alive, and zero motor function.

That's not continuity that is follow up for education and curiosity.

Continuity would be renewing her lovenox order on HD day #23 while you called long term care facilities to place her in her new persistent veggie state.

 

[Apollyon]

That's not continuity that is follow up for education and curiosity.

That's quibbling on your part.

 

[AmoryBlaine]

That's quibbling on your part.

Not really when you are talking about specialty choice. I really don't think saying "hey what ever happened to that guy?" to your IM colleague is the same as being someone's doctor for 20 years.

 

[Apollyon]

Not really when you are talking about specialty choice. I really don't think saying "hey what ever happened to that guy?" to your IM colleague is the same as being someone's doctor for 20 years.

Sure, you take extremes of examples, and you would be correct. But just define "continuity" - seeing how a patient did in the ensuing days or weeks, at least to me, is oftentimes gratifying or eye opening/humbling. It may be over-rated to you, but I see what you post. You can think whatever, and that you are correct, but your opinion that it is "vastly over-rated" certainly does not come from an experience standpoint. Do you think finding out from cards that the L main was 100% occluded is NOT continuity? You seem willing to draw bright lines, so I ask you what DO you call checking up to see how well or how poorly was your management in the subacute period?

 

[DeadCactus]

Sure, you take extremes of examples, and you would be correct. But just define "continuity" - seeing how a patient did in the ensuing days or weeks, at least to me, is oftentimes gratifying or eye opening/humbling. It may be over-rated to you, but I see what you post. You can think whatever, and that you are correct, but your opinion that it is "vastly over-rated" certainly does not come from an experience standpoint. Do you think finding out from cards that the L main was 100% occluded is NOT continuity? You seem willing to draw bright lines, so I ask you what DO you call checking up to see how well or how poorly was your management in the subacute period?

I don't think his point was to argue about the technical definition of continuity. Generally, when a person is concerned about having continuity in their specialty choice, it's a desire to have that relationship with a patient that stems from caring for them daily during their stay on the floors and/or at regular visits over many years.

I don't think that anyone would argue that following up on patients is an educationally and personally valuable act...

 

[Apollyon]

I don't think his point was to argue about the technical definition of continuity. Generally, when a person is concerned about having continuity in their specialty choice, it's a desire to have that relationship with a patient that stems from caring for them daily during their stay on the floors and/or at regular visits over many years.

I don't think that anyone would argue that following up on patients is an educationally and personally valuable act...

His point was to argue. Have you seen anything else he's ever posted?

 

[DeadCactus]

His point was to argue. Have you seen anything else he's ever posted?

No, fair enough.

 

[gutonc]

His point was to argue. Have you seen anything else he's ever posted?

Pot? Kettle. Kettle? Pot.

 

[Apollyon]

Pot? Kettle. Kettle? Pot.

Ah, I disagree. I discuss; I can show you MANY times I've admitted I was wrong, or had my mind changed due to a persuasive argument presented by another party. I do NOT stand stolidly in one position, doggedly refusing to consider another point, or continue to man the sinking ship.

And, unlike other argumentative SDN posters, I also don't have to resort to telling people to "go **** your mother" - that is always a stirring, inspirational appeal to reason.

 

[RxnMan]

Pot? Kettle. Kettle? Pot.

 

[alpacafriend]

Pot? Kettle. Kettle? Pot.

The reality of your observation is obviously lost on its subject, but it still deserves a "good effort" mention

 

[Apollyon]

The reality of your observation is obviously lost on its subject, but it still deserves a "good effort" mention

In my experience, people who say certain things are "obvious" - aren't.

And, if you want to insult me, nut/ovary up and do it, instead of some oblique attempt at urbanity - obviously. And you're not even the first person to use their first post on SDN to insult me. It's been done - and better - by others. Obviously.

 

[Birdstrike]

I can just feel the flames stoking

 

[jbar]

I'm not taking sides, but "overy up" just entered my lexicon. +1

 

[Dwindlin]

I'm not taking sides, but "overy up" just entered my lexicon. +1

I am taking sides and he's winning.

 

[jbar]

I'm bi-winning. Tiger blood really helps in the ED.