other specialties practicing EM

[zontal]

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i've seen other specialists in the ER as covering ED physicians,especially in low volume ERs. Could anybody pls shead light on which specialties,other than ER physicians are by law allowed to man EDs, b/cos I've seen a lot of FPs,IMs,and surgeons as ER physicians.Does it have to do with primary care specialists,I've not seen Pediatricians in the ERs though,and if I may ask, other than ER physicians which other specialty is at least relatively qualified to fill the ERs where ER physicians are hard to find.
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Give and it shall be given unto you.Stay cool.

 

[EMRaiden]

If you want to do EM do an EM residency... There is no other way to gain the experience and unique knowledge base that is required to practice in an ED. There have been several studies that have shown that EM trained physicians provide better emergency care at lower costs than those practicing outside of their specialty.

That being said there area not enough EM trained physicians to staff every ED for every hour and there are probably many ED where the type of patients do not require EM training. There are also many IM/FP trained physicians who have been practicing for years and do quite well thank you.

Currently there are no "laws" limiting who can practice EM. The practice track to Board Certification through the American Board of Emergency Medicine has been closed since 1988 (although there are alot of angry practice track candidates out there ie Daniel v. ABEM).

"It's not the just test, its the also the training"

 

[Apollyon]

About 25% of FP graduates go to work in ED's; in Canada, the CCFP is one of two that grants EM boarding.

If you have NO desire to advance, and want to work in the ED, you can do FP.

However, logically, do an EM residency - why be equal, instead of the real thing?

 

[Coleman]

If you didn't need EM residency to practice EM, then why are we all here? Let's graduate med school and get a job as the MD (or DO) that we are in an ED and make our money early?

Why not? Because if you weren't trained you shouldn't do it. That is my opinion. Yeah, it is an ideal world because that is not possible yet, but it should be. I wouldn't want a FP performing a lap choly on me any more than I would want a FP diagnosing an MI in my grandfather. No offense to FPs, but this is not what they are trained for.

IM is different I feel. They may not know the algorithms of a code and trauma as well, but they know them, and could be okay if forced to. I agree that if you plan to practice EM, you should be trained in it. I kind of agree with the ACEP position in regards to moonlighting in the ED as well. Don't get me wrong, I am all for moonlighting, but in a clinic or urgent care, I don't think any 1st or 2nd year resident should work as a chief MD at an ED for moonlighting.

Boy, don't know where this soap box came from, I'll get down now.

 

[southerndoc]

Originally posted by Coleman
I wouldn't want a FP performing a lap choly on me any more than I would want a FP diagnosing an MI in my grandfather. No offense to FPs, but this is not what they are trained for.

IM is different I feel. They may not know the algorithms of a code and trauma as well, but they know them, and could be okay if forced to. I agree that if you plan to practice EM, you should be trained in it. I kind of agree with the ACEP position in regards to moonlighting in the ED as well. Don't get me wrong, I am all for moonlighting, but in a clinic or urgent care, I don't think any 1st or 2nd year resident should work as a chief MD at an ED for moonlighting.

Not all FP programs are created equal. The rural FP programs -- which usually constitute the bulk of FP programs -- usually are the only residency programs at their respective hospitals. As such, their residents get a lot of experience handling critical patients. I am on the last week of an FP rotation at one such site. I must say that I am impressed with the knowledge that the residents possess. They routinely admit MI's, CHF patients, strokes, etc. and manage them quite well. I saw several critical patients during my time here as a third-year medical student.

Rural ED's should NOT be staffed by internists. Why? A significant portion of ED patients are pediatric patients -- roughly 15-20%, although this can vary significantly by area. Pediatric training in internal medicine is usually limited to what the person had during his or her third year of medical school, which is hardly sufficient for practice. Stating that internists are qualified to staff an ED is like saying pediatricians are qualified to staff an ED. They are qualified to staff an adult and pediatric ED, respectively. However, their trauma experience is limited, and one would hope that a trauma surgeon would be nearby in case these people screwed up. (The same can be said about FP's having limited trauma experience, too.)

I agree with previous posts... If you want to do EM, then do an EM residency.

 

[Annette]

I agree that if you want to do em, do em. However, I did a rural family practice rotation in a critical access hospital. We took everything that came, including traumas, MI, strokes, etc. Granted, the only we did was to keep them alive until the helicopter came to take them away, but we did have to keep them alive.

 

[DocWagner]

My biggest worry happens when there is NO EM trained doc there at all. I have seen lots and lots of FP's and FP residents flail at the most simple run Cardiac arrests ...including intubations. This certainly includes traumas. As far as I know, only EM docs and surgeons take ATLS.
For the sake of the patient populations, there should be one EM doc available at all times.

 

[blackcat]

coleman - you don't want that fp to miss the mi on your grandfather...

there are many good ed physicians out there that never did the training..it is really up to the person. they just need to devote time to reading and learning to do the right thing.

the best reason to do em residency nowadays is to be marketable. as soon as we graduate enough physicians, all those non em trained people working in eds will be pushed out

 

[blackcat]

i don't know how it is in the civilian world, but in the army everyone takes ATLS, including the psychiatrists. although i'm prettysure that i wouldn't want a psychiatrist running a code on me. actually i guess it depends on the person, i know several psychiatrists that would be able to run a succesful code.

 

[Coleman]

you're probably right blackcat, it is definitely user-dependent, and any physician who studies will know it. I guess I was making a blanket statement based on the "interesting" experiences I have had in FP during my rotations. Motivation was low all around and there was not as great an emphasis on education as I would have liked.

 

[southerndoc]

Originally posted by DocWagner
As far as I know, only EM docs and surgeons take ATLS.
For the sake of the patient populations, there should be one EM doc available at all times.

FP's practicing FP don't take ATLS, but the FP's that practice EM do.

I know of a hospital ED that is staffed by 4 full-time FP docs. They are all ATLS certified in addition to ACLS, PALS, ABLS, etc.

A significant number of hospitals now require ED physicians to be certified in at least PALS, ACLS, and ATLS.

 

[CJLaw]

In Reading, PA at RHMC they do not have EM residents, rather their FP residency staffs the ED. I have not heard any complaints from patients, in fact RHMC is known as the best hospital in the area. For trauma, I think most are life-flighted to Lehigh Valley, where they have a HUGE trauma center. Hope that helps.

 

[DocWagner]

I mispoke...EM and surgery are required to take ATLS. Of course EVERYONE is required to take ACLS, PALS, BLS etc.

I guess, from what i have seen, though many can work in an ED...the EM docs and residents (of course speaking from personal experience) LIVE FOR THE ED. They thrive on it.
That is who you want in charge...right?
I have never seen a FP resident make a bee-line for the patient on the back board as soon as they enter the ED...they wait, wait, wait...
This is why there are residencies for EM...so we can stay in the environment we like the most (and learn evidence based medicine to facilitate treatment decisions/options).

 

[blackcat]

i also think that the mentality of the EP and others are different. IN EM you are trained that this encounter with the patient may be the only encounter the patient is going to have and we need to make it count. we see so many unreliable patients and never know if they will actually follow up.
also, i think the expectation in the ER is higher than maybe in a clinic. if a diabetic comes to er with nausea/vomiting and malaise, we are expected to make sure this person is not having an MI, the expectation is to prove everything today not to try these meds and come back tomorrow for a recheck as is done in a lot of clinics. i just think we are held to a different stadard. we must consider everyone an emergency unless proven otherwise. my experience with others is that they are not emergencies until proven otherwise. and to give others the benefit of the doubt, most are not emergencies and most people do well, just the thoughts of the ep.

 

[zontal]

I thank you all for your input in this issue.However one thng that i observed while reading these opinions is that a lot of guys did backlash FP, example,an opinion about not trusting FPwith neither cholesystectomy nor MI. Let me understand one thing here,is it then a waste of tax payer's money to train FPs for three years if they cannot be trusted with anything,and why is their training as long as most other specialties.Also since ER is a new specialty,is it my understanding that GPs who where in our ERs b/4 the days of ER residency and who only did a year of internship post med school,where much more qualified than the current FPs in the ER,if not do I assume that the GPs killed a whole lot in those days.I tell you why I ask; I know this ER in OH with 70% FPs and 40%IMs simply b/cos there are no ERs who are willing to go man this ER.IM,EM,FP,how are we all going to work together to give the best to our patients.
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Give and it shall be given unto you. Be cool

 

[blackcat]

zontal - i think i've tried not to speak badly of fps. they are very good at what they do and they have an improtant role in medicine today. also, i think speaking badly about any field is stupid and immature since we are trained for different aspects of medicine and thus will all have our strong points and weak points....EM has many weak points and we are not the best physicians around.
however, we are trained to think what is the worst thing that this person can have and what will kill this person in the next 48 hours. others, including fp, don't necessarily have this approach to patients because that is not their training (nor should it) and i think the standard of care is not to think that way. the problem with their training not having this urgency (let me say not just fp but also all other nonemergent fields) is that the sensitivity to life threatening conditions is lowered.
on the flip side, since em is so highly trained to have such a high sensitivity, our specificity is lower than other fields.
each field has plus+minuses it is just what you are willing to deal with. EM is just a different beast.

docwagner - i don't think the fps have to make the bee-line to the backboarded person..if they wanted to do that they would've chosen EM or trauma.
i know fp trained ER physicians who are just as good as EM trained physicians. It just has to do with what someone wants to do with their lives professionally and have that high sensitivity mentality.

 

[Azalo]

"we are trained to think what is the worst thing that this person can have and what will kill this person in the next 48 hours. others, including fp, don't necessarily have this approach to patients because that is not their training (nor should it) and i think the standard of care is not to think that way. the problem with their training not having this urgency (let me say not just fp but also all other nonemergent fields) is that the sensitivity to life threatening conditions is lowered."



I work in a ER (am not a doctor) and I dont get the impression that the doctors treat every patient as if they might have a life threatening condition. All of our doctors are EM certified and from prestigiuos programs (Hennepin, Emory, Trinity, etc). They think 90% of our patients have BS complaints just like the rest of us. or at least that is the impression I get.

 

[blackcat]

azalo - i've worked as a physician in the er for the last 3 1/2 years. 90% of my patients are BS. however, it is my responsibility to THINK of the worst case scenario and rule that out. although ruling out can be something as simple as doing a quick history or physical. not everyone with chest pain needs to have enzymes done. not everyone with abd pain needs a CBC. however, all the bads things need to be considered and ruled out one way or the other.

 

[Azalo]

Can an EM certified doc practice as a family practice doc if s/he wants?

 

[Annette]

You can do liposuction and lasic procedures if you want, and you can find a place that will let you use their facilities (or you can purchase your own).

 

[womansurg]

Originally posted by Annette
You can do liposuction and lasic procedures if you want, and you can find a place that will let you use their facilities (or you can purchase your own).

First time you have a bad outcome - and you will, everyone does sooner or later - the medical community would hang you out to dry. You wouldn't be able to find a plastic surgeon or opthomologist (you do mean 'lasik' - the laser eye surgery?) who would say anything to a jury other than that you were acting irresponsibly and outside of your field of training.

 

[Sheerstress]

Can an EM certified doc practice as a family practice doc if s/he wants?

EM trained docs can work in more than emergency departments. They can do Urgent Care work, Occupational medicine, and could probably be approved to staff most any walk-in clinic. There are many such clinics in rural areas where it can be very difficult to get anyone to staff them, and the organizations that run these clinics would probably not have a problem with an EM-trained doc working there.

At one walk-in clinic near where I work, a former general surgeon from our hospital is on the staff. And at our hospital, we have some internal medicine and FP-trained physicians who have never done anything BUT emergency medicine work. Internists and Family Practitioners who work in ERs usually have taken all the requisite "merit badges" (ATLS, ACLS, PALS, APLS), read Tintinalli or Rosen, and gotten whatever additional training (e.g. CME courses) they need to get the job done. So there's no reason a physican from a close specialty couldn't "cross-train" and do a competent job.

With that said, although many internists and FPs can competently staff emergency departments, the real questions are

1. Is this best for the patients?

and

2. Is it best for the specialty?

The answer to the first question probably varies from physician to physician. There are certainly some FP-trained docs doing a very good job in ERs, and there are probably some incompetent emergency medicine residency trained docs out there as well.
In the long run, it is probably the emergency medicine residency trained docs who are best suited to handle critically injured patients, since that is what they are specifically trained to do.

As for the second question, it is certainly in the best interests of the specialty to have emergency medicine residency trained docs doing all the staffing. The whole point behind having a specialty is the assumption that a given group of patients, whether it be kids, adults, the mentally ill, or the critically ill/injured, require medical practitioners who are specially trained and have a specific set of skills best suited to deal with that group's specific needs.

If that is not the case, then one cannot argue against having FPs, etc. staffing emergency departments, or against having residents from other specialties moonlighting in ERs. Such habits perpetuate the notion that "anyone can staff an ER," a belief that the specialty of emergency medicine is trying to combat.

 

[Sheerstress]

First time you have a bad outcome - and you will, everyone does sooner or later - the medical community would hang you out to dry. You wouldn't be able to find a plastic surgeon or opthomologist (you do mean 'lasik' - the laser eye surgery?) who would say anything to a jury other than that you were acting irresponsibly and outside of your field of training.

It comes down to what you are comfortable doing. If, as a primary care physician, you are trained and competent at reducing simple fractures, you can go ahead and do them - if not, you should pass them on to the orthopedic surgeon.

If you mess up in patient care, you get sued; If I mess up, I get sued.

 

[Annette]

Womansurg, yes, I meant lasik. Spelling is not my forte.

My point was that any licensed physician can legally do any procedure, or advertize any services offered by any specialty. I had hoped people would infer that it wasn't necessarily a good idea from my glibness.

 

[womansurg]

It's true that anyone can be sued for anything. And a bad outcome in no way equates to malpractice. But a physician's defense of a lawsuit is dependent upon the willingness of colleagues to step foward and provide professional testimony about the appropriateness of your actions and judgment.

If (when) you are doing lasik and have a bad outcome, every optho in the country would jump on the bandwagon to railroad you out of your medical license - and not unreasonably, in my opinion. A parade of "eye surgeons" from esteemed institutions, with credentials as long as your arm are going to impress a jury a hell of a lot more easily than some local FP or ED doc who might be willing to stand up and say you did the right thing - if you can even find one.

Also, procedures which are done under the umbrella of hospital or clinic provisions are subject to approval. I can't go to my local hospital and do a heart bypass - they would not grant me privileges since I can't demonstrate adequate background training in that area (i.e. a completion of a cardiothoracic fellowship).

Just this year, a longstanding subspecialty surgeon in our community - who also is an attorney and teaches at the local law university - tried to do a percutaneous tracheostomy at the ICU bedside, lost the airway, and the young trauma patient died. Because this surgeon wasn't specifically trained and approved by the hospital to conduct that particular procedure, and because a barrage of trauma surgeons and pulmonologists were willing to step up and support the claims that he had acted irresponsibly and with poor clinical judgment, this guy lost his hospital privileges, was fired from his group, and is being investigated by the state medical board. He'll probably lose his license to practice medicine.

This is serious stuff folks.