Prepping for EM from IM

[Bostonredsox]

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So long story short...originally back in the day was planning EM/CC....ended up IM/CC but with family and financial obligations and such fellowship is just not really an option. CC hospitalist jobs far and few between in the area I plan on practicing, everyone wants pulm/cc trained or its to the floors for you. I cant work as a pure Gen med hospitalist, I will kill myself.

So I am looking at taking an EM job after my initial hospitalist contract expires. Most EDs have around 8-10% patient volume that are criticall ill, thats better than the 0% I will see as a GMF hospitalist and I can get my procedure and CCM fill that way. I am nervous about Peds. I havent seen sick kids other than my own since med school. Wondering if burning one of my final electives on a Peds Em month at a tertiary care center is worthwhile? Also, any other rotations that would be useful to make me more ready to be a community EM doc. Or am I worried about nothing. Input appreciated.

 

[Flopotomist]

So before you get a bunch of snarky comments below, let me help you understand why it is offensive. Most of us on here are either in a residency where we will spend 3-4 years learning EM, or are attendings who have spent even more than that training for this particular field. To practice EM without this training in today's world is simply to practice without complete and adequate training. Period.

Are there imbalances between the number of trained EM physicians and the number of EM jobs? Sure - but that does not negate the fact that without training or experience (for those grandfathered in) you are inadequately prepared to work in an ED, and one simple month of elective will not allow you to "catch up" to those of us who have worked for years to earn the right to call ourselves EM trained docs.

Yes, your CC time will benefit that small subset of critical care patients. However, you will be woefully underprepared for your OB patient, your orthopaedic patient, your pediatric patient, your patient that needs a chest tube, needs sedation etc. The list is very long.

Accept that you are unprepared, and practice knowing that, get the training, or practice in an area that you are trained in.

 

[NERDY]

Don't most EDs want BC/BE EM docs? How do you plan on doing EM without completing an EM residency?

 

[EMquest3]

So long story short...originally back in the day was planning EM/CC....ended up IM/CC but with family and financial obligations and such fellowship is just not really an option. CC hospitalist jobs far and few between in the area I plan on practicing, everyone wants pulm/cc trained or its to the floors for you. I cant work as a pure Gen med hospitalist, I will kill myself.

So I am looking at taking an EM job after my initial hospitalist contract expires. Most EDs have around 8-10% patient volume that are criticall ill, thats better than the 0% I will see as a GMF hospitalist and I can get my procedure and CCM fill that way. I am nervous about Peds. I havent seen sick kids other than my own since med school. Wondering if burning one of my final electives on a Peds Em month at a tertiary care center is worthwhile? Also, any other rotations that would be useful to make me more ready to be a community EM doc. Or am I worried about nothing. Input appreciated.

I can't answer your question, but I am hoping you are willing to answer a related one. Does EM/CC have the same problem with finding jobs as IM/CC? I didn't know that IM/CC was considered less desirable than pulm/CC. I would have thought CC fellowship put you on a pretty even ground.

 

[NERDY]

I can't answer your question, but I am hoping you are willing to answer a related one. Does EM/CC have the same problem with finding jobs as IM/CC? I didn't know that IM/CC was considered less desirable than pulm/CC.

Some where during the interview cycle I remember an "issue" was brought up where EM/CC doctors can't supervise IM residents/fellows on core rotations (since the attending is not IM trained). Not sure if this is true over all or I just misunderstood but just thought I'd share.

 

[Bostonredsox]

thanks for the quick responses.

To answer them,

1. I am not IM /CC, i want to be and this was my intention, but I cannot afford to spend the 2 years working like a fellow for 50k. my wife wants a house, my kids have needs, just not economically feasible.

2. I am aware of the desire for BE/BC EM in the ED. And I know I will not be as good of an EM doc as you guys....Reread my post..my original plan was EM/CC. THat is what I always wanted. It just didnt work out that way given the complexity of the AOA/ACGME match and family/geographic constrictions. However, just as EM trained docs are better suited to handle the EM patients by a signficiant margin, the CC trained docs are better trained and have better (leapfrog) outcomes than generalists practicing in the ICU. That said....<25% of ICU patients are seen by a CC fellowship trained doc. The shortage is too great. The same is true of EM. Outside academia, in the majority of community EDs (which outnumber the academic tertiary cares 10:1), maybe 1-2 out of 10 docs are EM boarded. There just isnt enough. The shortage is in the thousands. For that reason, surgeons, FPs, Internists and such brunt the load for the majority of community Em patients. I realise the training is not the same, (this is why I want my CCM boards in the MICU I just unfortunatley cant at this point in my life) but that doesnt mean I shouldnt see MICU pts.

I wasnt asking what rotations I can take to make me equal to you. Of course I will never be the same, I am an internist and you are an ED doc. I was asking for what type of things I could do to help my knowledge should I choose to practice community EM as an internist for a few years till fellowship becomes an option or I just burnout entirely.

And for the record I have trained and been privaledged for moderate sedation and I would wager that unless you did many extra trauma months I probably have more chest tubes than you 😛

 

[dotcb]

You may want to consider something like this:

http://www.ceme.org/pediatric-emergency-medicine-conference

You'll also need to learn some orthopedics.

While I understand your situation is not ideal, I think most EM physicians would feel something like this: we could fake it for a while as hospitalists, intensivists, family physicians, or even (gulp) anesthesiologists - doing so is bad for patients and frankly dangerous. The problem is - practicing a field you didn't train in is ripe for problems. The problem is - you don't know what you don't know until you're in over your head or make a mistake. While this might fly in the developing world or on medical missions, I feel the standard in the US is just higher and it just seems like a bad idea.

While I understand the standard of EM at your hospital may be low, and you may know 60-70% of EM, and with study might be able to bring that up, the standard for practicing EM and being board certified in the field is know close to 100% of the field, so you are really ready for whatever rolls in the door. My 2 cents...

 

[tkim]

A lot of the places who will take a non EM-boarded doc to work are places you may not want to work at or live in. Even those require a couple of years of practice in the ED before they will take you. Have you considered urgent care?

 

[gro2001]

The problem is that given your background of IM, your particular knowledge gaps are really dangerous for you in the ER. I am sure you can probably manage a sick septic patient as well as the next guy. However, medico-legally you would be much better off having a huge gap in CC knowledge and screwing up a case like that than miss any of:

-well appearing 2 month old with fever who you decided not to LP because he is afebrile in the ER that turns out to be a meningitis
-the fall on outstretched hand with pain that you decided not to splint because the xray is negative that turns out to be an occult scaphoid fracture
-retained foreign body in a laceration
-corneal abrasion that you did not ask about contact lenses

And how about the 'dastardly deeds'?
-Thoracotomy
-Cricothyroidotomy
-Lateral canthotomy
-Perimortem c section (or even a normal vaginal delivery?)

 

[SoCuteMD]

Some where during the interview cycle I remember an "issue" was brought up where EM/CC doctors can't supervise IM residents/fellows on core rotations (since the attending is not IM trained). Not sure if this is true over all or I just misunderstood but just thought I'd share.

My understanding is that in order to supervise, the fellow needs 6 months of internal medicine training in residency. This is achievable in some residencies - mostly 4 year programs with elective time.

To the OP:
I'm sorry that family/financial pressures have limited your career choice. I know that must be difficult. I think taking an EM job is a risky proposition for a number of reasons (both training/education and job security). From my perspective, I find that I use the knowledge gained on the following rotations on a near-daily basis:
1) ICU - not just MICU, but some PICU (moderately useful), and SICU (sadly, as much as I hated it, quite useful). MICU was by far the highest yield, but I learned a lot in SICU as well.
2) General surgery and trauma surgery - again, I hate to admit this one, but it was really really useful in learning to speak the language of my surgical colleagues and learning a little bit more about what they need to know from me to help them care for the patient.
3) Ophthalmology.
4) Pediatrics. Useful for perfecting my speech on "why your child isn't sick now, and what to watch for so that you'll know if they get sicker and need to come back." Even at the highest acuity peds hospital you will see a lot more runny noses and sore throats than you will see resuscitations (and good luck getting procedures - you'll be in line behind the fellows and any peds/EM senior residents). Becoming anywhere close to comfortable with sick kids requires lots of time spent in the peds ED. This means 4 months in my residency, plus a significant pedi volume and frequent pedi resuscitations at our secondary site, where we spend several months a year.
5) Ultrasound

 

[glorfindel]

I would recommend looking at the EM core curriculum required by the RRC for EM residencies, and identifying those things that you haven't been exposed to. I think a Peds EM or PICU rotation would be helpful for someone trained in IM.

There, that's my advice.

Now, on to the other issue, which as it has been framed by the responses on this thread is roughly "WTF OMG what are you thinking practicing EM without an EM residency!!!"

That's a serious issue and I won't minimize it, but I won't presume you aren't already aware of the problems, and I won't claim it's like announcing you plan to molest children or rob banks. Not the same order of magnitude folks -- just chill out for a bit.

Yes, in a perfect world everyone in an ER would be EM residency trained. As time passes we are moving towards that perfect world.* . I agree with dotcb that in the reverse scenario I or any other EM doc could fake it as a hospitalist and that it would be a bit dangerous (e.g., as a fake hospitalist I would never check a B12 level or get an iron studies panel (??) and even if I did I wouldn't know what to do with the results).

But this is not a perfect world! As Bostonredsox notes, there is an EM doctor shortage. There are plenty of community ERs in rural places who will hire IM or FM trained doctors so long as they have the merit badges (PALS, ATLS, etc) and they sometimes also require ER experience. Until those departments can find EM doctors, I'm glad that there are IM or FM trained doctors who will work there, because they do a lot of good for their patients and they save lives.

I am not an EM-residency-training nazi, in other words.

*I mention in passing the recent passing of the anomalously-run Harborview Medical Center ED in Seattle, where Dr. Michael Copass had established an alternative version of EM that the rest of the nation had not bought into, in which there was no such thing as an emergency medicine specialist. That model may have worked or it may have sucked (I don't know since I never trained or worked there) but it has died because, despite whatever virtues it may have had, Copass's model never caught on anywhere else. Now of course, Harborview's ED is staffed with EM-trained doctors and UW has a brand-new EM residency program.

 

[ptarmigan]

Most EDs may have about a 10% CC billing rate, but it is probably only 1-5% truly critically ill patients that you are actually going to find interesting. Those critically ill patients you are going to have to deal with very quickly, because the chest pains and belly pains keep rolling through the door. If critical care medicine is your passion, you are going to hate working in the ED. If you love emergency medicine, that's a different story.

What about commuting to a smaller hospital that needs an intensivist or moving to a more rural area where you can be an intesivist, or at least practice at a hosptail that has an open ICU?

About 50% of the patients you see in the ED will draw upon your internal medicine skill-set. The other 50% will be women, trauma, kids, and the surgical subspecialties such as optho, ENT, urology, neurosurg. That's like seven entire specialties that you know absolutely nothing about.

I am dissapointed that the standards in the ICUs are so much higher than they are in the EDs around your parts.

You cannot afford to practice emergency medicine. You are taking considerable legal risk by practicing in areas you have no training or knowlege in and you are putting your family in jeopardy. For a family practice doc, it is not as much as a stretch - but for internal medicine it is crazy.

And you cannot afford not to pursue specialty training in the specialty you are passionate about. Critical Care/Pulm is an incredible specialty and you will be forever unstaisfied and dissapointed if you do not pursue your passion.

Good luck. I hope you find a career that gives you satisfaction.

 

[Bostonredsox]

thanks for all the responses guys. I am hoping my misery will wear my wife down and agree to a CC fellowship. We shall see how things go. I have heard of local community shops 'financing' a fellowship if you come back to work for them after. That could help with financial burden of the fellows salary if its true. And I do like EM. I went to med school to do EM. But realised along the road that CC is where my heart lies. Hopefully the CCM shortage stays worse than the EM shortage.

 

[gutonc]

thanks for all the responses guys. I am hoping my misery will wear my wife down and agree to a CC fellowship. We shall see how things go. I have heard of local community shops 'financing' a fellowship if you come back to work for them after. That could help with financial burden of the fellows salary if its true. And I do like EM. I went to med school to do EM. But realised along the road that CC is where my heart lies. Hopefully the CCM shortage stays worse than the EM shortage.

Obviously this will be program dependent, but some of the CCM fellows at my program make $3-6K/month moonlighting during their 2nd year (first year is obviously way too busy). Just a thought.

 

[Bostonredsox]

Obviously this will be program dependent, but some of the CCM fellows at my program make $3-6K/month moonlighting during their 2nd year (first year is obviously way too busy). Just a thought.

Yeah its partly money, partly time. Working 7 on 7 off for an avg of 40 hours per week compared with fellow hours + moonlighting hours...after working 80+ per week for 3 years, my wifes like enoughs enough I am tired of raising kids alone. I get that.

 

[TheERdr]

I know this is unrelated, but I am actually curious..how many chest tubes have you done? The internal medicine residents where I train basically never do them...thoracentesis - yes, chest tube - no.

 

[Janders]

Bostonredsox, not sure where you are geographically.... but if you are truly near Boston proper, there are almost NO ERs that will hire non-EM trained physicians at this time. I know a lot of people who had YEARs of experience doing EM, but were trained in IM, Gsurg, etc... they have been pushed out recently and are all working urgent care now. This is, to my knowledge, basically true over anywhere within an hour's drive of the city.

Now if you are in rural New England, Western Mass, or somewhere else in the country... you certainly could still get hired in an ER.

 

[Bostonredsox]

I know this is unrelated, but I am actually curious..how many chest tubes have you done? The internal medicine residents where I train basically never do them...thoracentesis - yes, chest tube - no.

20+. I am not a typical medicine resident procedure wise, see hospitalist/1 year CC fellowship thread in CC forums.

And no I am not in Boston lol. I am from the northeast, but I am in souther virginia and will be practicing most likely in the northern north carolina/southern virginia area.

 

[Bostonredsox]

Bostonredsox, not sure where you are geographically.... but if you are truly near Boston proper, there are almost NO ERs that will hire non-EM trained physicians at this time. I know a lot of people who had YEARs of experience doing EM, but were trained in IM, Gsurg, etc... they have been pushed out recently and are all working urgent care now. This is, to my knowledge, basically true over anywhere within an hour's drive of the city.

Now if you are in rural New England, Western Mass, or somewhere else in the country... you certainly could still get hired in an ER.

This is my concern with being a CC hospitalist. I will work 10 years running a community MICU and then they will finally find a Boarded CC guy willing to come and I will get booted back to the floor.

 

[B-Bone]

I would advise against asking the OP how many procedures he's done. He is very confident in his skills.

http://forums.studentdoctor.net/showthread.php?t=978707

To the OP:
I can empathize with wanting to do CCM or EM. I think both are great specialties with lots of critical thinking and satisfying procedures. I can also empathize with family and financial concerns and the desire for an attending level salary. However, somewhere something has to give. The reality is that you are training in internal medicine and for the time being, at least, have no further training plans. I feel the concerns raised in this thread and the linked thread above are legitimate. While you may be able to find a job in an ICU or an ED, you are likely doing your patients a disservice by squeaking out of your appropriate scope of practice. In the long run, you may be doing you and your family a disservice if you have a bad outcome that leads to a lawsuit. I guarantee a plaintiff's attorney will have a board-certified EM of CCM expert witness testifying that IM training alone does not represent the standard of care in these areas (whether that's locally true or not). Again, no disrepect to your goals, interests, or skills. I just think that if you really want to go down these roads, you should get the appropriate training.

 

[Bostonredsox]

I would advise against asking the OP how many procedures he's done. He is very confident in his skills.

http://forums.studentdoctor.net/showthread.php?t=978707

To the OP:
I can empathize with wanting to do CCM or EM. I think both are great specialties with lots of critical thinking and satisfying procedures. I can also empathize with family and financial concerns and the desire for an attending level salary. However, somewhere something has to give. The reality is that you are training in internal medicine and for the time being, at least, have no further training plans. I feel the concerns raised in this thread and the linked thread above are legitimate. While you may be able to find a job in an ICU or an ED, you are likely doing your patients a disservice by squeaking out of your appropriate scope of practice. In the long run, you may be doing you and your family a disservice if you have a bad outcome that leads to a lawsuit. I guarantee a plaintiff's attorney will have a board-certified EM of CCM expert witness testifying that IM training alone does not represent the standard of care in these areas (whether that's locally true or not). Again, no disrepect to your goals, interests, or skills. I just think that if you really want to go down these roads, you should get the appropriate training.

Completlely understood. Make no mistake, I want to do a CC fellowship and I agree with all of your thought process. I think I am just a bit disheartened lately and felt like reaching about a bit. It is very unlikely I would actually persue a community ED job, I dont like sick kids. I hate orthopedics. Chronic paion makes my skin shrivel. More than likely I will just work in what CC shifts I can at my community shop whilst doing general hospitalist shifts otherwise and maybe after a few years my wife will see how unhealthy the misery is and I can squeeze in a fellowship. Thanks to all again for your comments.

 

[NERDY]

Completlely understood. Make no mistake, I want to do a CC fellowship and I agree with all of your thought process. I think I am just a bit disheartened lately and felt like reaching about a bit. It is very unlikely I would actually persue a community ED job, I dont like sick kids. I hate orthopedics. Chronic paion makes my skin shrivel. More than likely I will just work in what CC shifts I can at my community shop whilst doing general hospitalist shifts otherwise and maybe after a few years my wife will see how unhealthy the misery is and I can squeeze in a fellowship. Thanks to all again for your comments.

You don't get to pick your patients in EM. What will you do if you get an ortho patient or a sick kid? No one likes sick kids but it is our job to take care of them.

Medicine is a lot about delayed gratification - you have to put in the time/effort/work if you want the rewards at the end.

 

[NERDY]

Obviously this will be program dependent, but some of the CCM fellows at my program make $3-6K/month moonlighting during their 2nd year (first year is obviously way too busy). Just a thought.

I've heard the same at my program - that the fellows have great in house moon lighting opportunities.

 

[ptarmigan]

Reading through your post in hte CC forum, it is very clear that you do not understand what you do not understand regarding credentialling and procedures. You do not get credentialled to do anything in residency. Credentialling is an administrative hospital process with legal ramifications and it is for attendings only. Credentialling says"you can do this procedure on your own, unsupervized, and no one else has to sign off on it". It has nothing to do with an attending being in the room or not. You have a very simplistic view of supervision, thinking that it only means the attending is close by or in the room. That is not what supervision means in medical training - it has a much broader meaning.

You are operating under your attending's license no matter where he or she is. They are giving you a lot of leway either because they trust you or because they are lazy, but don't equate that to being credentialled. You are credentialled in nothing but busting your a** for your attendings and your patients.

It sounds like you have outperformed all the other residents in your IM program in terms of doing procedures. But that is not particularly impressive given that most of your colleagues don't care to do procedures. It's like saying I am a much better rock climber than someone who has never rock climbed before. You may feel very proficient compared to your colleagues, but I would caution you that this is not a useful comparison.

Experience with procedures bring humility.

 

[Bostonredsox]

Reading through your post in hte CC forum, it is very clear that you do not understand what you do not understand regarding credentialling and procedures. You do not get credentialled to do anything in residency. Credentialling is an administrative hospital process with legal ramifications and it is for attendings only. Credentialling says"you can do this procedure on your own, unsupervized, and no one else has to sign off on it". It has nothing to do with an attending being in the room or not. You have a very simplistic view of supervision, thinking that it only means the attending is close by or in the room. That is not what supervision means in medical training - it has a much broader meaning.

You are operating under your attending's license no matter where he or she is. They are giving you a lot of leway either because they trust you or because they are lazy, but don't equate that to being credentialled. You are credentialled in nothing but busting your a** for your attendings and your patients.

It sounds like you have outperformed all the other residents in your IM program in terms of doing procedures. But that is not particularly impressive given that most of your colleagues don't care to do procedures. It's like saying I am a much better rock climber than someone who has never rock climbed before. You may feel very proficient compared to your colleagues, but I would caution you that this is not a useful comparison.

Experience with procedures bring humility.

I am aware of what credentialling means in terms of its technical meaning. I am also under contract to be an attending at this hospital when i graduate. And when june 30th becomes july first, I will fill out a few forms, provide my procedure logs, and get formally 'credentialled' in all of the procedures i already do and do them exactly as i do them now. That is what I meant when i say credentialled. Nothing will change between june 30th and july first in terms of my skill or oversite. It just becoems a legal credentialling by the hospital. in practicallity, there is no change.

And I am not arguing with you over the procedures. i am too tired and worn out already to argue. I do not just feel proficient compared to my collegues, i feel proficient compared with the greater majority ofmy attendings here. To your analogy, does that just mean I have a bunch of weak attendings, sure. But either way, patients need the procedures.

And the humiliy comment is insulting. I am quite humbled when a bad outcome arises. They have and i am sure they will arise in the future. When one happens, like all of us, it is learned from so to try and prevent it from repeating. But it will never hinder me from performing a procedure on a patient who needs one.

 

[NERDY]

thanks for the quick responses.

To answer them,

1. I am not IM /CC, i want to be and this was my intention, but I cannot afford to spend the 2 years working like a fellow for 50k. my wife wants a house, my kids have needs, just not economically feasible.

On the interview trail, I met single parents, couples with many children, couples with children and no family support, etc. so if they can make finances meet, perhaps your family and you should reconsider wants vs. needs.

 

[Bostonredsox]

On the interview trail, I met single parents, couples with many children, couples with children and no family support, etc. so if they can make finances meet, perhaps your family and you should reconsider wants vs. needs.

Well there is alot that goes into a functional marriage and there is give and take on both sides. A spouse who hae been on the long ride with you through med schoola nd residency often raising kids alone without family help quite often sees your fellowship as 'something you want to do for you, but not something you need to do, you could have a great job making great money right now' they do not always understand the level of misery doing a job you hate for 30 years can bring after spending 11 years training for it. In my mind the fellowship is a need and not a want. That sentiment is not shared. Or it is just, well lets get stable then go back and do the fellowship in 8-10 years. That never happens. Once the path is started and the houses and morgtates and loan repayment starts, its very hard to go back to being a fellow.

 

[ptarmigan]

Man, sounds like a tough spot you are in. I have always thought the training pathways for the IM subspecialties are just brutal. I remember thinking interventional cardiology would be pretty cool but i could barely get through my IM rotation in med school let alone three years of it. I also thought peds CC would be cool but it was the same 3+3 model, and general peds being equally as painful.

I can certainly understand a spouse's retisence to sign up for three more years of post graduate training after three in the rear view mirror. Was your plan to do IM then CC all along and now she's changed her mind, or what happened? I wonder if you do 1 year as a hospitalist and try to keep living like a resident/sock a bunch of money in savings, if she will come around. Sometimes that sort of a comittment and patience with the other will make them want to return the favor.

 

[Bostonredsox]

Man, sounds like a tough spot you are in. I have always thought the training pathways for the IM subspecialties are just brutal. I remember thinking interventional cardiology would be pretty cool but i could barely get through my IM rotation in med school let alone three years of it. I also thought peds CC would be cool but it was the same 3+3 model, and general peds being equally as painful.

I can certainly understand a spouse's retisence to sign up for three more years of post graduate training after three in the rear view mirror. Was your plan to do IM then CC all along and now she's changed her mind, or what happened? I wonder if you do 1 year as a hospitalist and try to keep living like a resident/sock a bunch of money in savings, if she will come around. Sometimes that sort of a comittment and patience with the other will make them want to return the favor.

My plan way back was EM, tha became EM/CC, then forgoing DO EM spots for a shot at one year less ACGME EM turned into IM/CC. Yes it was always known I wanted to do CC but whether or not it would be feasible was always the question. I am hoping that running the community MICU at my shop, which I can do, jut not full time as there isnt enough volume to support it unless the 2 current guys are gone in 16 months, which is possible, for a few years will give me some peace. Maybe if i run a community shop for 5-7 years I can apply for a one year fellowship exemption, as the ID and other Im subspecialty boarded people are allowed to do, despite doing no CC during their original fellowship cept maybe cards. Or maybe shell come around. Or maybe I will stop caring. We shall see.

 

[Old_Mil]

So long story short...originally back in the day was planning EM/CC....ended up IM/CC but with family and financial obligations and such fellowship is just not really an option. CC hospitalist jobs far and few between in the area I plan on practicing, everyone wants pulm/cc trained or its to the floors for you. I cant work as a pure Gen med hospitalist, I will kill myself.

So I am looking at taking an EM job after my initial hospitalist contract expires. Most EDs have around 8-10% patient volume that are criticall ill, thats better than the 0% I will see as a GMF hospitalist and I can get my procedure and CCM fill that way. I am nervous about Peds. I havent seen sick kids other than my own since med school. Wondering if burning one of my final electives on a Peds Em month at a tertiary care center is worthwhile? Also, any other rotations that would be useful to make me more ready to be a community EM doc. Or am I worried about nothing. Input appreciated.

I don't mean this in a bad way, but as an IM physician who has not seen kids since medical school with a month of peds you are no more prepared to work in an emergency department than I would be prepared to work as an OB/laborist not having delivered any babies since my OB elective my first year of residency.

If you do this you will be putting your license at risk and taking on a huge malpractice burden. Remember that the staffing company who is willing to hire you for that job is most likely willing to do it because the job sucks and they are willing to put any warm body in the slot. They don't care about your r&#233;sum&#233; or career.

Don't do it.

 

[Bostonredsox]

I don't mean this in a bad way, but as an IM physician who has not seen kids since medical school with a month of peds you are no more prepared to work in an emergency department than I would be prepared to work as an OB/laborist not having delivered any babies since my OB elective my first year of residency.

If you do this you will be putting your license at risk and taking on a huge malpractice burden. Remember that the staffing company who is willing to hire you for that job is most likely willing to do it because the job sucks and they are willing to put any warm body in the slot.

Don't do it.

Agreed. But there are EDs with multiple providers on where you do not necessarily have to see the kids. But your point is well taken. It was just a really long day on the wards and my prospective soon to be here future seemed very very depressing at that moment.

 

[dotcb]

My last night shift was busy, with about 40% peds. Septic infant, sedated an 8 month old for a CT, and tried to sort out the sick kids from the ones with febrile viral illnesses. I wouldn't wanna be doing that without the 6+ months of peds I got in residency.

Other areas you'd likely be outside your element would be obstetrics and trauma.

 

[UnderwaterDoc]

How about working at a VA ED? No Peds, OB/GYN, or Trauma there, and they will love your procedural skills.

 

[K31]

But there are EDs with multiple providers on where you do not necessarily have to see the kids.

But aren't the EDs with enough volume to require multiple physicians also the ones more likely to them to be EM BC/BE?

It seems to me the EDs more likely to hire non-EM physicians are low-volume rural shops--ironically the ones where EM training is arguably more likely to be important since you're all alone and need to be able handle anything that comes through the door.

 

[NERDY]

Agreed. But there are EDs with multiple providers on where you do not necessarily have to see the kids. But your point is well taken. It was just a really long day on the wards and my prospective soon to be here future seemed very very depressing at that moment.

You don't control your patients. If a kid comes in and you are the doctor on, you need to see the kid. Perhaps, you need to show your wife the increased earning potential with a fellowship. Yes- you will have to spend a few more years living on a limited salary but when you finish you can earn more.

 

[tkim]

Now if you are in rural New England, Western Mass, or somewhere else in the country... you certainly could still get hired in an ER.

Not in my shop and none of the others in my area, though part of that might be because the other local hospital and it's 'satellites' have an EM residency, so the attendings need to be EM-boarded. There are 2/15 in my shop that are not EM-boarded, but they both have 30 years of ED experience between them, and that door has been closed for quite some time.

 

[tkim]

But there are EDs with multiple providers on where you do not necessarily have to see the kids.

Dude, if you were at my place and bumped peds and gyn cases at me because you didn't feel comfortable, I'd hate you.

 

[goodoldalky]

You can always give it a shot... See if you crap your pants on the first shift or not, if not, maybe it will work out. I say go for it.

 

[Brigade4Radiant]

Can someone please shed some light on why so many people don't want to practice general medicine? Most of the med students interested in IM want to specialize and few want to be hospitalists even though it has a sweet lifestyle.

 

[Bostonredsox]

Spend 16+ hours a day seeing 20 floor pts, 3 direct admits and 5 ED admits. Do that for 7 days in a row (12 as a resident) and see how your soul gets sucked out of you...

 

[glorfindel]

Spend 16+ hours a day seeing 20 floor pts, 3 direct admits and 5 ED admits. Do that for 7 days in a row (12 as a resident) and see how your soul gets sucked out of you...

So THAT'S why the hospitalists are grumpy when I call them! Their soul has been sucked.

 

[inspirationmd]

Agreed. But there are EDs with multiple providers on where you do not necessarily have to see the kids. But your point is well taken. It was just a really long day on the wards and my prospective soon to be here future seemed very very depressing at that moment.

Ok, so if you are going to try this then, as said above, you need to be aware you are taking a significant risk. I would say you need to do rotations in outpatient Orthopedics, Peds ED, Trauma/Gen Surg service an OB-Gyn/FM med OB service elective, and Ophthalmology elective at a minimum as well as a LOT of reading. You need to have logs saying you have delivered babies, reduced fractures, done a trauma resuscitation, etc in your New Innovations accounts. Hospital credentialing boards are paying more attention to this as well. Your ACLS/ATLS/PALS/NRP needs to be up-to-date and actually the last 3 you likely will be taking for the first time. Then you need to pick a low volume ED with near by back-up. I am talking ideally15K visits a year and definitely nothing more than 30K man.

A big problem you are going to have is that while it has been beneficial for your procedural training to be in a small community shop it is highly unlikely you will have an ability to get all these rotations even if they are available. Gen Med, Nephro, etc services have to be covered and that lazy attending in Rheum clinic who always wants someone to write his notes is not going to want to hear you can't rotate so you can see Peds cases as a categorical IM resident.

As mentioned, a big problem is that you are not trained to do this and that the standards for EM are more set in stone now. You need to know what to do with that listless kid with a fever until you can get your dispo. Peds IP may not be readily available. You will be held to the standard of what a BC EM doc would do, You won't be able to hide behind IM training. They will expect you to know and if you kick cases you are not comfortable with then your partners will quickly plot to get rid of you. Plus EDs like the ones you need are frequently single MD coverage with a PA or two.

You can try to find a VA job which you would probably be well trained for since they do not really see kids and there are not many women that present to those EDs but I suspect you have geographic restrictions that might prevent you from doing this. I hear the Durham and Richmond VAs are trying to get all BC EM docs on their payroll now too.

Dude I am going to be honest. You need to have a hard discussion with your wife about a CC fellowship. I have been reading your posts and doing boring progress notes/DC summaries for the umpteeth negative CP r/o or TIA work-up and working with SW to coordinate placement is something that might make you off your self. Have you suggested that you work your 1-2 years as a Hospitalist, stack major bank while helping change some diapers, and then go on to fellowship? There are still a lot of places that let their CC fellows do home call as back-up for the residents so you can still be available. Also more than 3 years out it is going to be very hard to go back as a CC fellow not only because of the financial hit but also programs get very squeamish about you the longer you are out of residency, plus I would imagine it would be harder to get one coming out of a small community IM residency.

Also the Hospitalist + 3 year plan and then eligible for 1 year CC fellowship and board cert will likely not happen for awhile. For whatever reason, CC is a political minefield. EM just got the ability to be board certified after fighting for over a decade. With the American Thoracic Society against the idea, its going to be a long battle regardless of what Leapfrog says. They will just say that the quality of training is being compromised and "patient safety" is at stake.

Good luck man. Your best option is to either convince the wife to let you do fellowship after 2 years or eat the Hospitalist route for a career and hope that pathway opens up (which she still may not be on-board with the 1 year hit in earnings and less help), or worse - take a clinic job. EM is not ideal and will expose you to liability and nebulous job security without board certification. Tough spot.

 

[PaddyMelt]

Agreed. But there are EDs with multiple providers on where you do not necessarily have to see the kids.

Haha, wow - you have just made sure to be universally hated by any EM-trained physician who ever works with you - congrats!

This thread is ridiculous. If you read the OP's thread in the CC-forum, he apparently has out-performed every single EM residency in the entire country. He has placed 100s of central lines, while only being supervised on 4-5 of them, he has intubated 50 patients, while only being supervised on "5-6" of them, he is "credentialed" to placed IABP's, and I stopped reading, but he may have cured cancer - AND he's still a second-year IM resident.

I'm still a resident, but the more I read, the more I'm insulted by your premise. Not only do you feel that you've out-learned all of us, but then you are willing to pass off patients that you don't want to see to other providers. You are the antithesis of EM, and are probably more suited to moonlight as a surgeon, given your attitude and willingness to avoid the cases you don't want to see...

 

[Bostonredsox]

Haha, wow - you have just made sure to be universally hated by any EM-trained physician who ever works with you - congrats!

This thread is ridiculous. If you read the OP's thread in the CC-forum, he apparently has out-performed every single EM residency in the entire country. He has placed 100s of central lines, while only being supervised on 4-5 of them, he has intubated 50 patients, while only being supervised on "5-6" of them, he is "credentialed" to placed IABP's, and I stopped reading, but he may have cured cancer - AND he's still a second-year IM resident.

I'm still a resident, but the more I read, the more I'm insulted by your premise. Not only do you feel that you've out-learned all of us, but then you are willing to pass off patients that you don't want to see to other providers. You are the antithesis of EM, and are probably more suited to moonlight as a surgeon, given your attitude and willingness to avoid the cases you don't want to see...

Your post is a joke. Not a single thing you stated has the slightest bit of truth to it. You clearly understood nothing in either of the threads. Thank you however to everyone else who had meaningful responses they were exaclty what I was looking for. Espec InspirationMD...I alrwady knew what you said, sometimes it just takes hearing it from someone else to make you feel more assured of your path.

 

[bigkahunaburger]

As others have said, do a 2 year ccm program. You'll have job satisfaction the rest of your life, you of all people need to do this, your passion for ccm is awesome. As a side note, even if "they" let you practice EM, can you imagine that the rest of your life? Woohoo let's triage people at 4am, then get yelled at for not getting people pain meds lol no thank you.

 

[PaddyMelt]

Your post is a joke. Not a single thing you stated has the slightest bit of truth to it. You clearly understood nothing in either of the threads. Thank you however to everyone else who had meaningful responses they were exaclty what I was looking for. Espec InspirationMD...I alrwady knew what you said, sometimes it just takes hearing it from someone else to make you feel more assured of your path.

Actually, I literally was quoting you about passing off your cases to other EM attendings. And then I was also literally quoting you about your IABP's, intubations and central lines. We are honestly to believe that your EM attendings call you to place central lines when they are unable to get them (from your other thread)?

But, my response was just a meaningful interpretation of how EM physicians may feel about the entire crux of your proposition, combined with your posting history...

 

[Bostonredsox]

Actually, I literally was quoting you about passing off your cases to other EM attendings. And then I was also literally quoting you about your IABP's, intubations and central lines. We are honestly to believe that your EM attendings call you to place central lines when they are unable to get them (from your other thread)?

But, my response was just a meaningful interpretation of how EM physicians may feel about the entire crux of your proposition, combined with your posting history...

What I was getting at is there are EDs with large staffs that I have worked in with multiple providers on meaning there will always be someone else there for help for a sick kid. I guess that can be interpreted as turfing cases so I will gie you that one.

As to the latter, yes. Many many times I have been called by my EM docs, who if you read clearily, are mostly old time FPs (2/16 our our ED docs are EM trained) I have been called to put in lines. Somestimes they are lazy. Sometimes they are 'too busy'. The majority of times it was 'we already tried 4-5 sticks in the subclav will you put in an IJ' (nearly none of them no how to use an US and despite many of us willing to show, the old timers have no interest in learning how to use the machine here). Maybe it just volume and bonuses for seeing more patients. Let the resident come take care of the septic shocker while I address these 9 chest painers. Either way, there is a HUGE physician inertia in my ED to performing any procedures or starting EGDT etc etc. All that can wait till they get upstairs in their opinion. As one of the FP ED docs here literally told me. "its not my job to figure out wahts wrong with them nor treat their condition, its my job to figure out if they are safe to go home or if you need to admit them". No joke. That is what I am working with.

I never, EVER implied I was better than EM docs as you put it. I do not consider most of the ED docs at my shop as real ED docs. They are a mixture of internists, FPs, a general surgeon and now 2 new EM guys. The majority of them are just shuffling chest pains and COPD exacerbations through the door to be admitted. There critical care knowledge and procedural skills are minimal at best. Do not extrapolate what I have done at my shop in response to the ED here, to the rest of the EM world. That would be a mistake on your part.