Question from FP resident

[il1234]

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I feel bad for causing such a controversy. Thank you guys for your comments (except squad). I just asked a simple question, I did not mean any disrespect to the field of EM. I have always gotton along well with EPs. In fact, EM was what I wanted to go into before I started Medical school. I changed my mind during second year of med school. My USMLE scores were above avg, my class standing was avg. Now I feel like I have made a mistake. It may sound stupid but I have been thinking about doing another residency in either PM&R or EM ( I know they are totally different fields). Some here expressed their sympathies, which is nice of you guys, but I am young in late 20s, single, handsome (no I am not looking to hook up with anyone here), my debt is under control. I have more energy compare to my M4 yr.

Anyway, I was looking for this kind of job when I started this thread (source American family Physicinan June 15/2007)
Indiana
Hobart, IN- Emergency Medicine opportunities at 25000 visit ED located 35 miles south of chicago and 15 miles northwest of valparaiso. Board certified/ board prepared primary care with emergency medicine experience. Shift is 11am-11pm and provides double coverage for board certified emergency medicine physicians. EPMG offers paid family medical benefits, incentive.............please contact.........

The above add is from june 15/07 but I just noticed it a couple weeks ago.
Squad's comments are very childish and unwelcomed. He reminds me of one of my classmates who was very uptight, guess what his wife divorced him during medical school and instead of learning a lesson he became even more uptight. Now squad is going to say that he is married. So what, you are still uptight.

Many times on this board, people applying to EM ask about burn out, and they ask wether they can practice as FP after practicing for EM for 15-20 yrs. Even though I dont recommend that, I don't see that as disrespect to FM.

 

[il1234]

sorry double posting

 

[jazz]

Anyway, I was looking for this kind of job when I started this thread (source American family Physicinan June 15/2007)
Indiana
Hobart, IN- Emergency Medicine opportunities at 25000 visit ED located 35 miles south of chicago and 15 miles northwest of valparaiso. Board certified/ board prepared primary care with emergency medicine experience. Shift is 11am-11pm and provides double coverage for board certified emergency medicine physicians. EPMG offers paid family medical benefits, incentive.............please contact.........

.

i entered the discussion when i felt that, in spite of squad's harsh tone, he had great points and was sticking up for the field of emergency medicine.

in the same post, i said that you had little idea what we do for as a specialty -- i take it back.

the above job advertisement shows that in smaller ER's in certain areas they must supplement coverage of an EM physician with a boarded primary care physician. in this case, it's expected that you wouldn't see the trauma, be expected to intubate, etc.

23 hours observation units exist -- sometimes they are under the auspices of medicine (in which case it's usually chest pain r/o obs units). if they are run by ER, they usually include all comers (chest pain, angioedema, abd pain, etc). but if you are looking to work in an ER setting, this is more like floor work

i personally know of someone who did 3 years of IM, then moonlighted in an ER for 1-2 years (he really struggled at it -- was basically winging a lot of things), then applied for EM residency and is currently about to finish off an EM residency.

i think if you're interested in ER, it's worth it to go back to training. in larger, more urban ER's, and also well off (i.e -- well insured) suburban ER's the trend is to go to EM trained/boarded physicians. apparently in the midwest (b/c eddible egg brings up the same scenario) it is not unheard of to have a low volume ER with EM physician coverage supplemented by a primary care boarded physician -- however, the pay difference may make it worthwhile to consider residency again.

as for urgent care/fast track, the acuity is so low which is why it's usually staffed by an NP/PA.

 

[Leukocyte]

, but if I was really sick I'd rather have the first person I saw be an EM doc than FM.

Whatever man. What are you talking about? So if you are "really sick" you would rather go to an Emergency Room and see an EM doc rather than go see your primary care provider?! If you have an emergency medical condition then sure, you MUST go to the ER, were the EM doc will seeyou, diagnose and treat your emergency condition, then after stabilizing you, he will contact/or tell you to follow-up with your Primary Care Provider.

EM docs and FM docs are DIFFERENT.

-EM docs are TRAUMA specialists, "traumatologists". They diagnose and treat EMERGENCY medical conditions. That is their job. They are NOT Primary Care Providers. Their diagnosis will not neccessarily be the same as the FM/IM/PEDS/OBGYN docs they call to admit the patient. EM docs H&P is MUCH more focused and targeted to the ACUTE setting.

-FM docs are Primary Care Providers. They are Ambulatory Medicine specialists. They are trained to be the primary physician for Inpatients and Outpatients. Quite often the EM doc's "admitting diagnosis" gets changed by the FM/IM/PEDS docs once the patient is admitted to the floor. They do their own NEW H&P and "RE-diagnose" the patient.

The two specialties have DIFFERENT focuses.

Emergency Rooms SHOULD be for Emergencies ONLY. They SHOULD NOT be utilized as a "cheaper" substitute to a visit to the Primary Care Provider.

-If I am having SOB and CP, I will do to the ER and see a EM doc for immidiate treatment.

-If I have a mysteious rash that has been getting worse for the past few days, I will go to my PCP, a FM doc.

 

[EdibleEgg]

The OP never said or even implied that he could do everything an EP can do. As a matter of fact he specifically stated that he was not comfortable flying solo and acknowledged his limitations. He simply asked if there were any opportunities in the ER for FP's, specifically mentioning fast track/ urgent care. I don't think he was trying to degrade the profession, he merely asked if he was worthy to work in the presence of BC EP's. I don't think anyone would debate that EP's are better at emergency care, but if FP's can't handle urgent care, that's just sad.

 

[roja]

Whatever man. What are you talking about? So if you are "really sick" you would rather go to an Emergency Room and see an EM doc rather than go see your primary care provider?! If you have an emergency medical condition then sure, you MUST go to the ER, were the EM doc will seeyou, diagnose and treat your emergency condition, then after stabilizing you, he will contact/or tell you to follow-up with your Primary Care Provider.

EM docs and FM docs are DIFFERENT.

-EM docs are TRAUMA specialists, "traumatologists". They diagnose and treat EMERGENCY medical conditions. That is their job. They are NOT Primary Care Providers. Their diagnosis will not neccessarily be the same as the FM/IM/PEDS/OBGYN docs they call to admit the patient. EM docs H&P is MUCH more focused and targeted to the ACUTE setting.

-FM docs are Primary Care Providers. They are Ambulatory Medicine specialists. They are trained to be the primary physician for Inpatients and Outpatients. Quite often the EM doc's "admitting diagnosis" gets changed by the FM/IM/PEDS docs once the patient is admitted to the floor. They do their own NEW H&P and "RE-diagnose" the patient.

The two specialties have DIFFERENT focuses.

Emergency Rooms SHOULD be for Emergencies ONLY. They SHOULD NOT be utilized as a "cheaper" substitute to a visit to the Primary Care Provider.

-If I am having SOB and CP, I will do to the ER and see a EM doc for immidiate treatment.

-If I have a mysteious rash that has been getting worse for the past few days, I will go to my PCP, a FM doc.

I am not really a traumatologists. Nor is trauma my specialty. It is a small part of what I do. I have heard the word 'emergentologist' but to me, this is just silly. You are dead on about treating acuity though.

However, getting in to the ER is rarely about it being cheaper and often about ease. Or a misconception as to what is an emergency. Or they call thier doctor for thier fever,cough, etc they have been riding out for 3 days and they can't get in for another 2 weeks.

The entire system is screwed. And, as I always tell third and fourth years, if you are going to be angry about people coming to the ED for 'non-emergencies' you are in the WRONG field. This is just a part of EM and if you hate it, it may not be the field for you.

 

[Leukocyte]

I am not really a traumatologists. Nor is trauma my specialty. It is a small part of what I do. I have heard the word 'emergentologist' but to me, this is just silly. You are dead on about treating acuity though.

I said "traumatologists" because the EM attendings at my medical school kept refering to themselves as "traumatologists" and saying "I went into EM becuase I was always interested in traumatology". However I do agree with you that trauma is only a part of EMERGENCY medical situations.

However, getting in to the ER is rarely about it being cheaper and often about ease. Or a misconception as to what is an emergency. Or they call thier doctor for thier fever,cough, etc they have been riding out for 3 days and they can't get in for another 2 weeks.

The entire system is screwed. And, as I always tell third and fourth years, if you are going to be angry about people coming to the ED for 'non-emergencies' you are in the WRONG field. This is just a part of EM and if you hate it, it may not be the field for you.

No the ER visit actual bill is way to high. I used the word cheaper in quotation because many people with no medical insurance of ability to pay just go to the ER whenever they have a medical problem, emergent or non-emergent. They go there b/c they know that they will be never turned down for lack of insurance. And for some, when they receive the HIGH ER bill, they just do not pay it...thus my use of the word "cheaper".

ERs SHOULD (should) be used for ACUTE/EMERGENT medical conditions ONLY. They should not be places were you get your (non-emergent) medical conditions diagnosed and treated. FM docs spent 3 years training to be PCPs and are the ones who SHOULD be seen first for any (non-emergent) medical condition.

-EM docs CANNOT do all what FM docs do.

-FM docs CANNOT do all what EM docs do.

-Can an FM doc handle many emergencies - YES

-Can an EM doc treat many PCP issues - YES

After all, they are BOTH M.D.s. Any M.D. can do anything with the correct training. It is not like your training is set in stone after your residency.

 

[docB]

While the tone is a little harsh 😉 I think Leukocyte's sentiments are right on.

However, any EP that refers to themselves as an "emergentologist" or especially a "traumatologist" gets a big 🙄.

 

[HokiMD]

you're joking right? you think an FP has more experience with acute abdomen? please, an FP who sees an acute abdomen in the office immediately refers it to the ER.

And what should an ER physician who sees a true acute abdomen in the ER with no **** peritonitis do? Call surgery ASAP, so to be honest with you, I don't see what that statement proves. I will leave it at that, b/c I really don't want to get into the ER evaluation of abdominal pain other than to say that I feel that is a component lacking in ER programs around the country as very few residents take a true rotation in GSurg or EGS.

 

[jazz]

my point is that we see a lot of patients with abdominal pain in the ER.

patients with a PMD who have acute abdominal pain (regardless if they have an acute abdomen) will likely be refered straight to the ER if they call their primary (b/c their PMD often cannot fit them in that day). even if they are seen in the office, they are either sent home with pepcid/protonix etc (meaning that the abdomen is not acute) or are refered to the ER.

are EM physicians particularly good at diagnosing acute abdomen? no for the most part anyone can tell when an abdomen is peritoneal and then obtain a CT scan for definitive diagnosis at which point the patient requires a surgeon. in this day and age, very few surgeons will take a patient to the OR unless there is a ct scan done (except for the case of possible ruptured AAA)

a large portion of our patients present as abdominal pain. the challenge is not figuring out the acute abdomen (again, i think that's obvious)... the challenge is deciding whether or not to CT scan the young patient with miedpiastric/periumbilical pain with n/v/anorexia to r/o appy or treat as gastroenteritis. the challenge is not to attribute low back pain/flank pain to kidney stone when it is a leaking AAA.

i don't think rotating through a month of general surgery will make any difference. by the time a patient is admitted to the floors of general surgery the diagnosis has been made. and even if you think doing consults with general surgery will help, i don't agree since by the time the surgeon is called, the diagnosis is already made.

and i'll ask again - -just curious are you an ER resident?

 

[roja]

While the tone is a little harsh 😉 I think Leukocyte's sentiments are right on.

However, any EP that refers to themselves as an "emergentologist" or especially a "traumatologist" gets a big 🙄.

I knew there was a reason I liked you. 🙂

 

[Leukocyte]

I knew there was a reason I liked you. 🙂

You are talking to me, right? I thought so. I usually have this affect on the ladies😎......but sorry, green fairy, you are not my type. I more into tan brunettes Italian gals. But Irish maidens can be hot too...

 

[Leukocyte]

OOPS, sorry! You were actually refering to docB!😳

 

[JackBauERfan]

And what should an ER physician who sees a true acute abdomen in the ER with no **** peritonitis do? Call surgery ASAP, so to be honest with you, I don't see what that statement proves. I will leave it at that, b/c I really don't want to get into the ER evaluation of abdominal pain other than to say that I feel that is a component lacking in ER programs around the country as very few residents take a true rotation in GSurg or EGS.

I dont think this would be a deficiency in any EM residency. I would say any population of patients anywhere in this country, a majority of the patients would have some component of abdominal pain.

When I'm in the ED, I would say at least 50-60% of patients i see have straight out abdominal pain that needs to be evaluated. And now, contrary to popular belief, not all get CT scans, only the ones that end up getting evaluated by the inpatient teams (because they are probably the really sick ones). Most of them get discharged without any scans.

So I agree with jazz, a gen surg month would help out in a lot of aspects, which most residencies have trauma surgery, ent, ortho as requirements, but if its a gen surg month just to evaluate abdomens I dont see the point. Don't all of the patients admitted to a surgery inpatient team first get evaluated in the ED???

When I did my Medicine prelim year, we had a few patients directly transferred from another hospital, but greater than 95% are admitted through the ED.

So yeah, lots of abdominal pains in the ED.

 

[bartleby]

You should be thankful for every patient who decides to come to your ED and make a small contribution to that month's mortgage payment. It can also be gratifying to see a few patients a shift where 30 seconds after you're in the room you have a diagnosis and dispo in contrast to the rest of your patients who will linger for hours waiting for CT or admission.

The entire system is screwed. And, as I always tell third and fourth years, if you are going to be angry about people coming to the ED for 'non-emergencies' you are in the WRONG field. This is just a part of EM and if you hate it, it may not be the field for you.

 

[roja]

You should be thankful for every patient who decides to come to your ED and make a small contribution to that month's mortgage payment. It can also be gratifying to see a few patients a shift where 30 seconds after you're in the room you have a diagnosis and dispo in contrast to the rest of your patients who will linger for hours waiting for CT or admission.

😕😕😕



And Leuk, I was talking to docB. But its a bias. I also tend to snicker at those type that feel they must correct every living person that they don't work in an ER, etc.

And btw, I am not Irish. Its a common misconception. My family is prussian and cherokee and whatever.. 🙂

 

[deleted6669]

"in addition, the PA's that have worked years in an ER setting, work up medical problems from an Emergency Medicine approach (rule out the PE/dissection for CP) whereas someone who just came out of FP residency may work up medical problems like an internist....
furthermore, a lot of the PA's that staff FT/Urgent care centers have been at it so long that they are better at reading ortho/plain bone films that I am. I doubt that a FP resident sees that many ankle, wrist, elbow xrays in residency."

THANK YOU-
after working in em for >20 yrs and seeing over 100,000 emergency pts of all acuities I(and those like me) do have a better understanding of emergency medicine than an FP or IM doc right out of residency.I know this because I currently work at a facility with an fp residency and have worked at several others in the past. I precept these folks. I know a lot more em than they do. they certainly know more family medicine and primary care than I do because that is their specialty.
emergency medicine is mine.
the emergency residency trained and boarded physician is certainly the gold standard in emergency medicine. no arguement about that from me. an fp doc with YEARS( >10) of emergency medicine experience is second best( and much better than the internists who do no ob, trauma, kids, etc). the next best thing( and far better than ANY new FP/IM grad) is an experienced em pa. currently I staff a 28k pt/yr dept. solo at night(I'm there right now) as well as staffing a rural facility where I alternate charts with a doc in addition to a position at a busy trauma ctr.
I knew from early on that I wanted to do em. I did emt in high school. er tech through college. I was a paramedic for yrs and then did a pa program with a focus in em including trauma surgery( I still do atls every 4 yrs), peds em(and still do pals every 2 yrs), 17 weeks of em electives as well as all standard primary care rotations(all with an inner city focus and hands on procedural skills). all my cme is em related: fccs, the difficult airway course, etc. I did a postgrad masters in emergency medicine and a postmasters yr in adv. clinical studies in family and emergency medicine. I have served as associate chief in a community emergency dept.
I am a peer reviewer for em articles in a widely read journal and have written many em artcles as well. I am on the planning committee for designing a new emergency dept at a rural facility (the current staffing model plan is for 24/7 pa's with docs on day shift as double coverage). I am a member of the federal disaster medical team, etc

there is a place for fp docs in em but they need to prove themselves just like anyone else. start fast track or urgent care, do all the required certs/cme, learn all the adv. procedures from your em trained colleagues, and with time ( if you want) go work solo in a rural facility and be the attending . at the rural facility I work at about 1/2 of the attendings are family medicine trained. they are all excellent. they have also all been at it longer than I have...

 

[HokiMD]

Well, I guess that I'll go ahead and go down the road I was trying to avoid.

As for what I am training in, a chance to cut is a chance to cure. I'm not revealing local, b/c I am THINKING of changing fields, but have made no concrete decision, so cat is not out of the bag.

I will preface this by the following: please read my post in its entirety and take a look at it in its whole, and if it angers you, think why, and who you should actually be angry at.

Do I think it is hard in this day and age to be an ER physician? NO. Do I think it is hard to be a GOOD ER physician? YES. Do a little research and I believe you can find some info on a nurse (or some other non doctor health field worker) I believe in CA who practiced as an ER doc for a long number of years w/o anyone's knowledge until recently. Why? B/c he consulted ALOT. In this day and age of medicine, with the superspecialist and the option to consult at the drop of a hat, to practice ER is not particularly difficult to do IMO with an MD. My problem is that a substantial amount (not saying all, not saying a majority, but more than there SHOULD be) of ER residency trained physicians practice as if all they do is manage consults. I can not tell you how many times I get the call in the middle of the night "I have a patient with abdominal pain" and that is it at a tertiary referal center!!! No diagnosis, little workup, just abdominal pain. And its sad. I've seen a patient with no **** peritonitis sit in the ER for OVER 9 hours after a full chest workup (which was negative) and a CT scan was done to wait for the OFFICIAL READ to show obvious extravasation of contrast into the abdominal cavity. Now as Jazz said an acute abdomen is rather obvious, how did a ER residency trained physician miss that obviously exam? Or how about a patient with fever, tbili of around 5 and chest pain sent home on a Z pack for pneumonia (depending on physical exam that could be Reynaud's triad)? I'm not making these up. Or a missed Kehr sign for a spleen lac....The list goes on. So as a surgeon, I don't trust an ER physician's exam or diagnosis unless I have personally worked with them for a substantial amount of time (meaning I don't buy any argument stating that an ER physician does an abdominal exam that is better or even comparable to a surgeon's, or that all the abdominal workup in the ER has made them into an excellent clinician with respect to abdominal pain).

I also find it funny the constant referal to CT scans....WE DO NOT OPERATE ON A CT SCAN, we operate on a patient. I've see many patients taken to the OR w/o a scan b/c a good physical exam tells me what I need to know. I've seen many an appy that had a negative CT scan that final path came back appendicitis. The excuse that a surgeon won't see a pt without a CT scan is crap, b/c I can tell you where I train and where I went to med school that is wrong. I will see a patient without a CT scan, and there was an article recently that showed there were better outcomes if a surgeon was brought on board for appendicitis b/f CT. The reason a surgeon doesn't want to come down is b/c in my experience there are a substantial number of times ER doc has done a piss poor workup of the patient, has no clue what is wrong with the patient, and is just consulting b/c they have that option (and read my definition of SUBSTANTIAL above)

To add onto that, I'll add more: Do I think it is hard to be a FP or IM doc? NO Do I think it is easy to be a GOOD FP or IM doc? YES. I think this all comes down to the way medicine is practiced today. I see too many hopsitalists that all they do is consult. They make no attempt at finding a diganosis, just consult a service to do it. And its sad, you go to medical school and through residency to practice that way!!!!! The way medicine is practiced in a hospital today is quite sad with all this "managerial" medicine both in the ER and on the floors.

If you find what I'm saying condescending, so be it. But don't be mad at me, be mad at your colleagues. Be mad at your board certiftying committees that let these "ER trained" docs into practice. Be mad at them for practicing medicine the way they do, and be mad at their coworkers who won't step up and point out what is wrong. Yes, there are fine ER docs, and I have worked with them. Yes, I think it is beneficial for a physician who plans to work in the ER to go through an ER residency. Do I think it is neccessary? NO. With all these ****ty physicians that go through ER residency and are allowed to practice, I have no problem with an FP practicing in the ER as well, especially one who acknowledged his limitations. If you want to talk about how the ER should be mainly ER trained physicians, clean up all the trash and then we can talk. Otherwise I don't care what your training is, b/c in all honesty, they couldn't do much worse than some of the docs I've seen in the ER already.

 

[jazz]

to HokiMD

i had a feeling you weren't an ER resident which i think makes it hard for you to talk about the specialty and field of emergency medicine....

i believe your stories and i think the view point from each specialty is different. i can tell you that where i went to medical school, residency, and the last 2 hopsitals i've worked as an attending, i've had 2 cases (peds) where i can remember a surgeon taking a pt to OR without a ct scan (excluding penetrating trauma).

i have no idea where you are training and i'm not asking you to tell but i have some questions --
who works in your ER? are they board certified EM physicians? i'm not sure you know the answers b/c the history of emergency medicine and board certification is complicated. there are people who are grandfathered in and are great at EM (they are the "grandfathers" of the field). then there are people who grandfathered in and still practice like internists. i worked with one physician who for abdominal pain would get a flat plate/obstruction series, when negative, would obtain a CT Scan non contrast, then when negative would obtain a CT scan with IV contrast, and then when negative would obtain a surgical consult. This person was BCEM (grandfathered in and trained in IM). Do I find the above plan of care ridiculous -- of course -- if i were a surgery resident getting this consult, would this be one of the stories i repeat over and over to make fun of ER physicians -- probably. Does this mean we are all "*****y" physicians -- no.


And just on the flip side -- i've worked with some bad surgeons. Do i think that the whole field of surgery is worthless. No. I realize that those particular surgeons are bad....

I don't necessarily find your post condescending. We live and work in a fishbowl and hindsight is always 20/20. We are used to ignorant rants and raves from consultants and specialists who think they can do a better job than we can (without taking into account how many patients we are juggling at once and the vast spectrum of problems we are managing at a given time (respiratory distress, acute MI, appy, ectopic, etc). I feel like your post generalizes the field of EM and is based on your limited experiences with what sounds like a less than stellar ER group.

Best of luck to you in whatever you specialize b/c in the end, you'll be a practicing physician and will rely on consults from the ER and the floors (IM docs) to make money.

 

[docB]

Well, I guess that I'll go ahead and go down the road I was trying to avoid...

I strongly disagree with just about everything you have said here. I also don't view this as being constructive criticism. It certainly sounds like the bitterness and venting that is created by residency. And the comments that it is easy to be even a mediocre EM, IM or FP doc is insulting. The attitude that only your own specialty is difficult is pure arrogance.

The situations you describe are all examples of the 20/20 hindsight from consultants that we live with but we don’t have to suffer gladly. For every bad EP story you have I’ll be happy to throw you a story about any specialist you name that’s worse. For every unnecessary CT an EP does there’s a specialist who refused to see the patient before a CT was done.

If you have no respect for EM or IM or FM, which interestingly will be your primary referral base in the future, that’s your issue although I think it will hinder you down the road. I am certain that few on the EM board will agree with or appreciate your position.

 

[Jeff698]

HokiMD,

I'm sorry, were you saying something?

I lost interest right after it became apparent that you had nothing constructive to say.

Take care,
Jeff

 

[txterp98]

Or how about a patient with fever, tbili of around 5 and chest pain sent home on a Z pack for pneumonia (depending on physical exam that could be Reynaud's triad)?

Reynaud's triad? You mean Reynold's pentad? Or perhaps you're referring to Charcot's triad?

Whatever.

In any case, the rare cases of cholangitis nowadays are managed by ERCP with sphincterotomy than surgically with common bile duct exploration anyways.

But what would I know. I'm just a run-of-the-mill ER consulting scut monkey.

 

[HokiMD]

I strongly disagree with just about everything you have said here. I also don't view this as being constructive criticism. It certainly sounds like the bitterness and venting that is created by residency. And the comments that it is easy to be even a mediocre EM, IM or FP doc is insulting. The attitude that only your own specialty is difficult is pure arrogance.

The situations you describe are all examples of the 20/20 hindsight from consultants that we live with but we don’t have to suffer gladly. For every bad EP story you have I’ll be happy to throw you a story about any specialist you name that’s worse. For every unnecessary CT an EP does there’s a specialist who refused to see the patient before a CT was done.

If you have no respect for EM or IM or FM, which interestingly will be your primary referral base in the future, that’s your issue although I think it will hinder you down the road. I am certain that few on the EM board will agree with or appreciate your position.

First, where in my post did I say that only my specialty was difficult? That was what you inferred, not what I stated. I'll be the first one to admit there are ****ty surgeons in addition to ****ty IM, FM, EM or what not....whats the commonality in all this, they are ****TY DOCS!!!!But instead of addressing the problem at hand, you just brush off my opinion as just a rant or vent, we shouldn't take a look at ourselves, should we? We shouldn't sit there and say what could we do to change this? No, its just a total misconception, we should just turn a blind eye and let things go as they may, b/c these people are just venting/raving/spewing off steam for no good reason. Heaven forbid it was your family member that underwent these obvious errors. Heaven forbid it was your mother sent home b/c a CT scan was negative when in actuality they had appendicitis and now need out their entire cecum.

Maybe I should clarify this further. Do I think it is difficult to get into med school? YES. Do I think it is challenging to go through med school? YES. Do I think ANY residency is a challenge to get through? YES. Do all of these mean that a person will continue to practice medicine the way it should be afterwards? NO NO NO NO NO. There has been a distinct change in the climate of medicine over the past 10-20. Yes, it has something to do with technology and science. But more of it has to do with the social side of medicine. First is the attitude of society, a huge huge change across the board from how things were done 20-30 years ago in all fields (look at the attitude of the 20-40 y/o crowd vs the over 40 and its quite obvious). Too many people say its not my problem, thats someone else's job, etc. Again, this is not the majority, but it does not need to be a majority to have a significant impact does it? With the amount of patients a doctor manage, 5-10% of the docs that may practice with this attitude, and it would have a huge impact. Secondly, the super specialization of docs nowadays. This makes it so easy to manage a patient with consultants. And unfortunately a large number of people, doctors included, will take the easy way out. Like I said, a non MD/DO worked in the ER in that capacity for several years based solely on that principle. With the prevalence of hospitalists, there IMO is too much of a shift to this "MANAGERIAL" medicine. I sit there and look at what these hospitalists consult nowadays and I wonder why they even bothered to go through med school or residency. And this is not an effective medical strategy, it costs more money to get these consultants in, and it loads consultants down who are better served to see more critical patients more deserving of their expertise. So yes, with all these consultants available nowadays, it is easy to practice IM, it is easy to pactice FP, it is easy to practice EM, and it is also easy to practice surgery. To practice them well is another story entirely.

And I think the one thing that probably is a sad thing is two posters said I should refrain from letting my feelings be known over inadequacies of a doctor due to referral base. So my concern for the patients well being and the level of care they get should be put aside for business reasons? If I wanted to make money, there are other easier paths than medicine.

I respect EM, IM, FPs, or any doc who practices medicine well. We all make mistakes, that is obvious. What bothers me is when it is this same people that continue to make the mistakes, yet we do nothing about it. I see the need for EM residency, I respect that, and I respect the majority of ER doctors that are practicing. What I don't respect is the trash that clouds all specialties, and the effort or lack thereof to get rid of it. Speaking from a surgical standpoint, we fire people from our residency, if they can't cut it they are gone. We are very stringent on licensing, and yes we are very cutthroat amongst our own. I'm not saying our way is the best, but I see too many times an IM or FP doc get through b/c either a.) its the path of least resistance to pass them through or b.) they don't have the bodies to fill the position. I've seen Ato be true in ER but not so much B And here within lies the problem, we are alowing subpar residents make it into practice. I"m not saying go back to pyramided residencies, or renewing contracts, but some changes need to be made. Yes hindsight is 20/20, but if we don't look at our mistakes how can we correct them.

I also noticed another statement about the volume load. Well, I understand that, all doctors for the most part have a high patient load. If that is the case, why the resistance to an FP or IM, or someone to help reduce that patient load and take care of the less critical patients. It allows you as an ER doc to focus less on the crap you didn't want to see and truly practice with the patient acuity you envisioned. Just MO.

If we don't look at ourselves, and find what is wrong within our own group or specialty and attempt to fix it, how can we ever grow as a person, specialty, profession or society. I'm sorry if you thinkI am an @sshole surgeon, but tell me another way to change this if that be the case and I'd be more than supportive of it. Yes, it doesn't take much to create a stereotype. But it also doesn't take much in medicine to severely change/cramp/interfere with the practice of all specialties

 

[jazz]

And I think the one thing that probably is a sad thing is two posters said I should refrain from letting my feelings be known over inadequacies of a doctor due to referral base. So my concern for the patients well being and the level of care they get should be put aside for business reasons? If I wanted to make money, there are other easier paths than medicine.

by responding to this, i'm probably prolonging this discussion and inevitably HokiMD's responses.

however, just to comment. i think we all know that there are much easier paths than medicine to make money.

from your posts, you come across as a very arrogant and ignorant person (a person who looks down on all specialties except for surgery). as a result, though you are entitled to your thoughts and opinions, don't be surprised if people are turned off by them. for all i know, you may be a great surgeon, but i'm sure you will be practicing with great surgeons who are also more respectful to their colleagues and likely to their patients. if i had a choice b/w consulting one or the other, the choice is obvious.

 

[txterp98]

Hoki, I agree with your last post. No matter what specialty, there will always be good and bad docs. In fact, that holds true in all professions outside of medicine as well.

In my opinion, your recognizal of the increasing specialization of medicine making practing medicine more easy is correct. I also agree that the work ethic of residents today is nothing like it was in the past - which is unfortunate.

If the point of your posts is not meant to be inflammatory but to bring attention to the fact that we must all find it in ourselves to work harder and pay more attention to details in order to become better doctors, then your last post has done a good job saying so.

I have to admit, your first few posts came across as more accusatory and inflammatory. I'm not trying to be defensive, just explaining how it was perceived. In any case, I wish you the best in your current specialty or in the new one you are considering if you do switch.

 

[southerndoc]

So as a surgeon, I don't trust an ER physician's exam or diagnosis unless I have personally worked with them for a substantial amount of time (meaning I don't buy any argument stating that an ER physician does an abdominal exam that is better or even comparable to a surgeon's, or that all the abdominal workup in the ER has made them into an excellent clinician with respect to abdominal pain).

That's understandable. I personally don't trust a surgeon unless I know him well enough. Word of mouth means a lot in our industry. I'm amazed at the number of botched surgeries that happen.

I also find it funny the constant referal to CT scans....WE DO NOT OPERATE ON A CT SCAN, we operate on a patient. I've see many patients taken to the OR w/o a scan b/c a good physical exam tells me what I need to know. I've seen many an appy that had a negative CT scan that final path came back appendicitis. The excuse that a surgeon won't see a pt without a CT scan is crap, b/c I can tell you where I train and where I went to med school that is wrong. I will see a patient without a CT scan, and there was an article recently that showed there were better outcomes if a surgeon was brought on board for appendicitis b/f CT. The reason a surgeon doesn't want to come down is b/c in my experience there are a substantial number of times ER doc has done a piss poor workup of the patient, has no clue what is wrong with the patient, and is just consulting b/c they have that option (and read my definition of SUBSTANTIAL above)

The reason a surgeon won't see a patient without a CT scan is not because the ED attending did a piss poor job examining the patient. It's because it's 3 am and he/she doesn't want to drag their lazy arse out of bed. Get the CT and you delay the consult by at least 3 hours (2 hours after the contrast, CT to be performed, and then read). "Wow, it's 6 am - my alarm clock is going off! Guess I should see the consult now."

In all honesty, very few surgeons take patients to the operating room without a CT scan. At one of our community hospitals, one of our attending surgeons FREQUENTLY takes patients to the OR without CT's. We love it when he's on. We call him up and the patient is off to the OR. He's "old school," but we love it. It gets the patient out of the ED quickly, which frees up space for the next unlucky person waiting in the waiting room. More importantly, it gets the patient to where he/she needs to be without the added radiation and contrast exposure.

Please post your experience after you've been an attending for 2 or 3 years. I'm curious if you'll consult on patients at 3 am without a CT scan.