Other careers within EM??

[Dookter]

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Hi, I'm a 3rd year med student at Duke. I've been giving my future career a lot of thought lately. Duke has a strange program in that I've already completed all of my rotations during my first two years and am doing research right now. I say this only to point out that I've already seen just about everything I will be able to see before applying and have a serious interest in EM after going through all my rotations, including an EM elective. I've also really enjoyed being around the faculty and residents in the EM department here and think I've found a personality match in terms of a career.

However, one of my last remaining major questions about EM is this--if a person does burn out and decides he/she needs to switch careers at some point, what other career options are available as a doc with EM training? Can you work in a minor medical center? Are there fellowships that set you up for a career working outside of the ED? Are there opportunities to, 👎, work as a PCP?

I ask this only because it seems that in many other fields such as internal medicine subspecialties there is usually a "way out" if you wake up at age 50 and decide that this isn't for you anymore.

I'd like to point out that I ask this question not out of a lack of real interest in EM or any anticipation of wanting to change careers. I'm starting to think more and more all the time that EM is really where I want to be. However, I like to make major life decisions with thought and preparation. Any input on this topic would be greatly appreciated.

 

[tybalt]

There was a thread about this a while ago. "Non-ED job options". Here is the link... though I warn you that some of the answers are "special" 😛

http://forums.studentdoctor.net/showthread.php?t=570311&highlight=non+clinical+job

 

[Hallm_7]

It's my opinion that EM is probably the most flexible when it comes to the ability to work in areas outside the environment you trained in. There is a huge variability in the types of EDs you can work in....from 6000 patient/year at some rural hospitals to 100,000 patients per year at urban centers.....trauma heavy......nonexistent trauma.....rural.....urban....etc.

You can also work outside of an ED and feel completely comfortable. Hardly anyone does it, but I think ED docs would make great PCPs. You would need to review preventive medicine, but that wouldn't take all that long. As far as acute care visits I would say EM physicians are probably more comfortable with that than FPs. There are people with far, far less experience running PCP offices than EM physicians (think of all the freshly minted NPs and PAs with little oversight). Urgent care is also an obvious option for burned out EPs. So is occupational medicine if you can stand the boredom. If you wanted you could return and complete a critical care fellowship and work in a unit. This is a growing area for EPs. You can also do the same for toxicology, although most tox guys continue to work a reduced number of ED shifts.

You could also stay within the healthcare realm but not practice medicine. It's my belief that EPs are probably the most qualified physicians in the hospital to move into management since they are really a merger of all specialties. No other specialty can claim a broader base of knowledge which is very important for administrators to have. Plus, EPs are generally very likeable people and are natural leaders (maybe I'm biased though). There are also numerous posibilities with local, state, and federal governments in regards to EMS direction, police medical direction for swat, state disaster preparedness, federal disaster planning, etc.

Lastly, EM allows its physicians to transition into unrelated fields because it affords the EPs time to retrain and pursue other interests. You can work it out to work a shift or two a week and finacially be comfortable compared most other people. Given the flexible schedule you can easily return to school for an MBA to go into business or get a JD to practice law. Or if you wanted to start another type of business you could arrange your schedule to do so (real estate, medical spas, etc). Of course, there's always politics as well. MDs are highly respected by the local community (especially small communities), and should find it fairly easy to get involved and elected.

In general, I think all of medicine affords a great variety of options if people are interested in taking them, but no other specialty matches the variety available to EM. This is one of the greatest aspects of EM. At no time should any EP feel like they are tied to the job if they begin to have burnout or other interests.

 

[tybalt]

It's my opinion that EM is probably the most flexible when it comes to the ability to work in areas outside the environment you trained in. There is a huge variability in the types of EDs you can work in....from 6000 patient/year at some rural hospitals to 100,000 patients per year at urban centers.....trauma heavy......nonexistent trauma.....rural.....urban....etc.

You can also work outside of an ED and feel completely comfortable. Hardly anyone does it, but I think ED docs would make great PCPs. You would need to review preventive medicine, but that wouldn't take all that long. As far as acute care visits I would say EM physicians are probably more comfortable with that than FPs. There are people with far, far less experience running PCP offices than EM physicians (think of all the freshly minted NPs and PAs with little oversight). Urgent care is also an obvious option for burned out EPs. So is occupational medicine if you can stand the boredom. If you wanted you could return and complete a critical care fellowship and work in a unit. This is a growing area for EPs. You can also do the same for toxicology, although most tox guys continue to work a reduced number of ED shifts.

You could also stay within the healthcare realm but not practice medicine. It's my belief that EPs are probably the most qualified physicians in the hospital to move into management since they are really a merger of all specialties. No other specialty can claim a broader base of knowledge which is very important for administrators to have. Plus, EPs are generally very likeable people and are natural leaders (maybe I'm biased though). There are also numerous posibilities with local, state, and federal governments in regards to EMS direction, police medical direction for swat, state disaster preparedness, federal disaster planning, etc.

Where did you hear that Emerg. trained physicians allowed to work as a PCP? I was under the impression that you would have to complete another residency as FP or IM to do this... Someone please correct me if I'm wrong (I know you will...)

 

[Hallm_7]

Let me flip the questions around: How can family medicine-trained physicians work in the ER?

The simple answer is that any MD can work in any setting. Legally a family medicine doc or EP could perform a CABG tomorrow without any formal training as long as a hospital gave them privileges. Obviously, they wouldn't get privileges, but it highlights the fact that from a legal position all MDs are equal in regards to scope of practice. The restrictions are only put in place by hospital credentialing committees who tell every physicians what they can and cannot do. Many, many (even a majority?) hospitals have allowed FPs to work in an emergency setting although it is definitely moving the other way quickly.

The thing about PCP offices is that they are completely independent of the requirement of privileges because the vast majority of practices are separate from those hospital systems. Even the "affiliated" practices are independent because the hospitals do not own them. Any MD or DO who has passed the three steps can hang a sign and practice primary care if they desire. All they have to do is get patients, and I doubt it would be difficult to get patients as an EP. I don't have any data, but I would bet the lay public views EPs as being more competent (right or wrong) at handling diseases because they know that we take care of critically ill patients all the time.

Board certification, in and of itself, doesn't allow an MD or DO to do anything extra. (As an aside, probably half of the surgeons performing cosmetic surgery aren't BE/BC in plastic surgery because most of them operate in outpatient surgery centers where privileges are either nonexistent or easy to get.) It does have hospital credentialing and third-party payer implications for procedures, but I doubt that comes into play for majority of E&M visits a PCP would see.

When you get into rural areas you will commonly see surgeons performing in both a surgery role and a PCP role. You will also find many physicians who only completed a year of internship with no formal residency training functioning as a PCP. Lastly, there are already NPs and PAs with less than half the education as MDs or DOs practicing essentially independently, and if they can do it you better believe a residency-trained MD can do it. There is a tremendous demand for PCPs in all areas, and as the old saying goes, "Beggars can't be choosers."

Lastly, you will be affecting peoples' lives so you would obviously need to fully grasp preventive care recommendations in regards to HTN, heart disease risk, DM, etc. You are held to the same legal and ethical standard as a FM or IM trained PCP in regards to what you would do for your patients.

 

[tybalt]

Let me flip the questions around: How can family medicine-trained physicians work in the ER?

The simple answer is that any MD can work in any setting. Legally a family medicine doc or EP could perform a CABG tomorrow without any formal training as long as a hospital gave them privileges. Obviously, they wouldn't get privileges, but it highlights the fact that from a legal position all MDs are equal in regards to scope of practice. The restrictions are only put in place by hospital credentialing committees who tell every physicians what they can and cannot do. Many, many (even a majority?) hospitals have allowed FPs to work in an emergency setting although it is definitely moving the other way quickly.

The thing about PCP offices is that they are completely independent of the requirement of privileges because the vast majority of practices are separate from those hospital systems. Even the "affiliated" practices are independent because the hospitals do not own them. Any MD or DO who has passed the three steps can hang a sign and practice primary care if they desire. All they have to do is get patients, and I doubt it would be difficult to get patients as an EP. I don't have any data, but I would bet the lay public views EPs as being more competent (right or wrong) at handling diseases because they know that we take care of critically ill patients all the time.

Board certification, in and of itself, doesn't allow an MD or DO to do anything extra. (As an aside, probably half of the surgeons performing cosmetic surgery aren't BE/BC in plastic surgery because most of them operate in outpatient surgery centers where privileges are either nonexistent or easy to get.) It does have hospital credentialing and third-party payer implications for procedures, but I doubt that comes into play for majority of E&M visits a PCP would see.

When you get into rural areas you will commonly see surgeons performing in both a surgery role and a PCP role. You will also find many physicians who only completed a year of internship with no formal residency training functioning as a PCP. Lastly, there are already NPs and PAs with less than half the education as MDs or DOs practicing essentially independently, and if they can do it you better believe a residency-trained MD can do it. There is a tremendous demand for PCPs in all areas, and as the old saying goes, "Beggars can't be choosers."

Lastly, you will be affecting peoples' lives so you would obviously need to fully grasp preventive care recommendations in regards to HTN, heart disease risk, DM, etc. You are held to the same legal and ethical standard as a FM or IM trained PCP in regards to what you would do for your patients.

I imagine one could be in legal trouble for practicing outside the area of one's expertise. I always thought of FP's working in the ED as a practice based on precedent -- There once was a time when EM wasn't a specialty and somebody had to work in the ED; somebody with training in adults, peds, and OB-Gyn. I personally think this is hardly the same as an EP deciding -- "gee, I think I would like to start working as a cardiologist. I'll begin by cathing and stenting some patients". One of my least favorite things in the world is the application of "blanket rules", i.e. taking one situation/rule and applying it everywhere without thinking about the actual differences between seemingly similar situations.

Is it acceptable for an EP to work as a PCP? I personally don't really know. Certainly an EP encounters many, many primary care issues on a daily basis.

How about an opinion from someone who is actually in practice (rather than 2 med students)? Have you ever heard of an EP going on to work as a PCP? Do you know the legal issues?

 

[danzman]

How about an opinion from someone who is actually in practice (rather than 2 med students)? Have you ever heard of an EP going on to work as a PCP? Do you know the legal issues?[/quote]

Along those lines, an ED doc I know works three shifts a week, Sat, Sun, Mon, 7A-7P. He takes Tuesday off, Wednesday morning goes in to his family practice clinic and sees patients, Thursday he works a half day in the clinic, Friday off, back to the ED Sat night. He has a PA that sees patients at the clinic M-F and he is responsible for looking over ten percent of the patient files. My understanding is that, technically, the clinic is owned by the PA, as he pays all the overhead and owns all the equipment, but the PA needs a doctor to oversee the clinic. For his day and a half of work the ED doc makes a salary not dependant upon patient load. This guy is older, all of his kids are in college, and his wife has a full time job, but he claims to make about a jillion dollars working four days a week. The clinic is strictly medicare/Medicaid and is in a rough part of town, but I think they have around 4000 patients.

 

[deleted65604]

The idea of an ER residency trained doctor working as a PCP is stupid. Cholesterol? What's that? Never ordered one in residency or changed my management as the result of the test. High blood pressure? Uhhhh... try hctz or atenolol. What to do with a funny looking PAP smear? Uhhhh... follow-up with your PCP, shoot, I am your PCP. Chronic asthma? Don't even touch that in ER... steroids and home in the ER, as out-patient, you want to limit steroids as much as possible. Behind on vaccinations? I've never helped someone catch up with modified strategy. Migraine prophylaxis? We never once had that conversation in the ER. Lupus work-up and chronic management? Never once diagnosed it in a patient. Breast exams for cancer screening? Never once tried to feel for a lump in residency. IBD- diagnosis and work-up and maintenance? Not an emergency. To say nothing of the management of chronic diabetes. In the ER, they need a drip, 5 units, 10 units, or just fluid hydration and f-u with PCP. I have no experience in meddling with people's chronic diabetes medications and for something so incredibly important, I would never feel comfortable without an additional 3 years of FP or internal medicine.

Why would you even think of doing an ER residency and then work as a PCP? ER jobs are everywhere. You get paid great (more than average PCP). If you want more money, you can moonlight in another ER for a couple of shifts a month.

 

[tybalt]

How about an opinion from someone who is actually in practice (rather than 2 med students)? Have you ever heard of an EP going on to work as a PCP? Do you know the legal issues?

Along those lines, an ED doc I know works three shifts a week, Sat, Sun, Mon, 7A-7P. He takes Tuesday off, Wednesday morning goes in to his family practice clinic and sees patients, Thursday he works a half day in the clinic, Friday off, back to the ED Sat night. He has a PA that sees patients at the clinic M-F and he is responsible for looking over ten percent of the patient files. My understanding is that, technically, the clinic is owned by the PA, as he pays all the overhead and owns all the equipment, but the PA needs a doctor to oversee the clinic. For his day and a half of work the ED doc makes a salary not dependant upon patient load. This guy is older, all of his kids are in college, and his wife has a full time job, but he claims to make about a jillion dollars working four days a week. The clinic is strictly medicare/Medicaid and is in a rough part of town, but I think they have around 4000 patients.[/QUOTE]

EM or FP trained?

I agree -- What's Cholesterol?

 

[danzman]

ER. I have faith that a good ER doc can manage hypertension, breast exams, and most other things a FP doc can. Maybe not all, but most.

 

[Aloha Kid]

Technically after 1 year of residency internship, we qualify as a general practitioner. So yeah, we can see clinic patients.

 

[Hallm_7]

The idea of an ER residency trained doctor working as a PCP is stupid. Cholesterol? What's that? Never ordered one in residency or changed my management as the result of the test. High blood pressure? Uhhhh... try hctz or atenolol. What to do with a funny looking PAP smear? Uhhhh... follow-up with your PCP, shoot, I am your PCP. Chronic asthma? Don't even touch that in ER... steroids and home in the ER, as out-patient, you want to limit steroids as much as possible. Behind on vaccinations? I've never helped someone catch up with modified strategy. Migraine prophylaxis? We never once had that conversation in the ER. Lupus work-up and chronic management? Never once diagnosed it in a patient. Breast exams for cancer screening? Never once tried to feel for a lump in residency. IBD- diagnosis and work-up and maintenance? Not an emergency. To say nothing of the management of chronic diabetes. In the ER, they need a drip, 5 units, 10 units, or just fluid hydration and f-u with PCP. I have no experience in meddling with people's chronic diabetes medications and for something so incredibly important, I would never feel comfortable without an additional 3 years of FP or internal medicine.

Why would you even think of doing an ER residency and then work as a PCP? ER jobs are everywhere. You get paid great (more than average PCP). If you want more money, you can moonlight in another ER for a couple of shifts a month.

I agree wholeheartedly with you on the question of why anyone would want to do primare care after completing an EM residency, but I'm sure there are people out there who would want that.

I do disagree on the management of chronic disease. Like I said before, there are NPs and PAs with a two year post-bac degree and no residency managing DM, Cholesterol, HTN, immunizations, and general non-emergent complaints. I would hope that after four years of school running up $140,000 in debt and a 3-4 year residency that I could better manage any of those diseases than mid-levels (and in no way am I am minimizing their importance by saying that). I've never heard of any family medicine guys managing either Lupus or IBD (although I would hope that any med school graduate could adequtely work these up from prior knowledge or by going to UpToDate). For management they punt to rheum/nephro and GI. Would an EP be as proficient as an IM or FP? No, but I think EPs would do an admirable job, especilly for areas that have too few PCPs.

Regardless, the question being asked was more one concerning the legalities of an EP doing primary care without doing an IM or FM residency. Without a doubt it is 100% legal, and given the severe shortage of PCPs in American I would say the overall health would improve in the country.

 

[docB]

If you have a medical license you can open an office and be a primary care doc. Should you? No. We routinely argue that you should be a board certified EP to work in an ED. The fact that non-BC docs do it doesn't change the goal. If we say that we are perfectly competent to work in a primary care setting then we are saying that IM and FM training and boards are not required and we invalidate our own argument.

The advent of midlevels, pharmacy clinics, etc. does muddy the waters. I agree that an EP is probably superior to an autonomous midlevel in a primary care setting in general but probably not to a supervised midlevel. That nugget of hard data is based on what I think but that's about it.

 

[Hallm_7]

I think I need to add that I do think residency training in IM or FM leads to better PCPs, and I am in no way saying that EM residency prepares you for a primary care practice like those specialties.