Rural FM and ER work??

[dr aaron]

Hello i am a medical student interested in practicing family medicine, I was wondering if anyone on this thread knows if one can successfully run a family practice maybe 4 days a week(assuming you have either a partner or a NP) and work 1 day in the ER in a small community hospital-i read somewhere that they are paying $125 an hour in some community ER's which would really help in paying off loans...does anyone know if this is possible to do?

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[deleted6669]

I work a weekend/month as double coverage at a small rural er that staffs 1 md 24/7 and a pa on day shift as well. the doc gets $145/hr. the docs are a mix of em and fp docs. I don't think any of the fp guys have a separate practice on the side although I don't see why they couldn't do it if they had a pa backing them up a few days/week. maybe the office is open 5 days/week with the pa working alone 2 days/week and with the doc 3 days/week and they share call. the doc could then do 3 days fp and 1-2 days in the er.

 

[hossofadoc]

Oh yeah! This is very the same exact thing that my father does, he has a FP practice 9-5 and then works in the ER about 9 shifts a month. I know that most of the rural ER's where I live in KY you can pull this off and most pay in the 100-200/hour range.

 

[sophiejane]

Physician staffing companies are actively recruiting FM docs for rural/suburban ER work. Don't let anyone tell you otherwise.

 

[racerx]

Physician staffing companies are actively recruiting FM docs for rural/suburban ER work. Don't let anyone tell you otherwise.

In my small hometown in WNY, the local hospital's ED director is an FM doc. Then only ED boarded docs are the rotating locums folks that work there.

 

[dr aaron]

Thanks for all the responses so far....I'm from Alabama and I would love to eventually practice FM in one of the small towns i grew up in, i just think that if I could make a few extra bucks working in a community ER to pay off these $250,000 in loans wouldnt be a bad idea

 

[allendo]

I'm thinking of going into ER and while I was home on Christmas break I hung out in the ER. The ER sees about 25-30k per year and most of the docs are FP, or IM/Peds guys, very few BC EM docs.

 

[f_w]

Where I practice, most ERs are covered by FPs. Few of them have a regular practice, most do ER work because they prefer to do the shift thing. We have a couple of FPs who do 2-3 shifts a month, as one put it 'to pay tuition for my son AND be able to retire at some point'.

 

[thedman888]

do these small town ER fp docs need to do some extra training in ER? or do they recruit grads from ER heavy residencies?

 

[Hayduke]

Hello i am a medical student interested in practicing family medicine, I was wondering if anyone on this thread knows if one can successfully run a family practice maybe 4 days a week(assuming you have either a partner or a NP) and work 1 day in the ER in a small community hospital-i read somewhere that they are paying $125 an hour in some community ER's which would really help in paying off loans...does anyone know if this is possible to do?

This revives a hot topic debated here about every 6 months or so.

To answer your question-"can I get a job in an ED as an FP".
As detailed by posters above the answer is "sure ya can".

Now if you are a patient-centered clinician your question should be "can I do the work of an EP?"

This will really depend on where you train, what is your patient base and in the new generation of FPs-who's got your back?

The job you are looking for means you are THE guy for any complaint coming through the door. Most folks will come in with the muscle aches/sniffles/ortho stuff you might see in the office. But when you are THE guy it means you have a responsibility to these folks to have a working knowledge and skill set that covers 4+ airway modalities, surgical procedures that make the difference in somone keeping a limb or their life, imaging knowledge hopefully including excellent facility with BS US and a universe of risk stratification knowledge.
Does your hoped for residency teach this?

I too am hoping to work in a rural ED. I cannot imagine being out there without the training I am receiving now in a high acuity, super busy trauma and cardiac center.

Just like Family Practice, Emergency Medicine is a specialty. It is a hybrid, so for the short term there will be positions. As the number of residency trained grads in EM expands, we will fill these slots.

Good Luck.

 

[sophiejane]

do these small town ER fp docs need to do some extra training in ER? or do they recruit grads from ER heavy residencies?

There's no such thing as an "ER-heavy residency" that I know of. The RRC sets requirements for curricula and they are all pretty much the same, with some variation. Most programs have 1-2 months of ED. What helps prepare and FP for the ED is lots of procedures, plenty of adult medicine and critical care, and good peds. And gyn. A trauma elective is helpful, and spending some of your elective time in the ED.

Before this turns into the flame-war it is likely about to turn into, know that the best ED doc is always going to be the board certified one. Unfortunately, there aren't enough of them, or enough of them willing to work part-time in little rural EDs, or to staff minor cares. That's where we come in. It will likely be many years before we see the recently increased number of EM residency spots turned into enough practicing docs in rural EDs that FPs are no longer needed.

The other thing is, if you are in a larger ED, you will almost always have a BC EP there as well.

The other thing that makes FPs attractive to recruiters is that we can fill a part-time position, and do clinic work the rest of the time. It's hard to lure someone with a family to a rural ED with part-time pay.

 

[dirtridndoc]

I agree. Yes, you can work in a rural/suburban ED if you are an FP. There are not enough EM residents to fill all of the positions in underserved areas. I am a PGY-III in a rural FP program with an EM/Acute Care Track. Originally my plan was to finish here and go work in a rural ER. In my second year, I realized that, even with my 15 years as a paramedic, there was no way I felt qualified to work in EM without completing a second residency in EM. Per RRC FP requirements, we get one month of EM in our intern year and one month in PGY-III. Even with the additional 2 months of Peds EM and Adult EM in Denver that the EM /Acute Care track provides, this - in my humble opinion - is still inadequate to feel confident working in an ED. I am applying for a second residency in EM.

Our ED just hired 2 recent grad ABEM cert physicians and the trend throughout our underserved state is going in that direction. Furthermore, there are more EM residency programs in states with underseved populations now and they will be turning out more EM physicians who may be willing to work the smaller ED's. Not everyone wants the "excitement" of the Knife and Gun Clubs of urban areas.

If you really love EM and want a career as an EM physician, then do an EM residency.

If you really love FP, do FP and hope to get good EM training in your program. Moonlight as much as you can so you can see what you are getting into. If you feel unprepared you can always do a second residency in EM or consider the FP EM fellowship.

Good luck to all this year.

 

[f_w]

do these small town ER fp docs need to do some extra training in ER?

Need: Yes.
Have: Some.

 

[f_w]

One of the reasons why EM trained docs don't take rural jobs is that they have unreasonable expectations about the income/work equation. A hospital with a 15k or 20k visit ER that sees the usual mix of medicaid, no insurance and medicare just won't be able to fund the $180/hr guaranteed incomes (of course with CME, vacation and full healthcare benefits) EM trained docs are looking for.

The competition for the FM docs doing ER work are the PAs and NPs willing to take those rural jobs for less money than a FP.

 

[deleted6669]

"The competition for the FM docs doing ER work are the PAs and NPs willing to take those rural jobs for less money than a FP."

agree-many small facilities use a mix of fp md's + em pa's. the pa's either work as double coverage so the facility doesn't have to pay for 2 docs at the same time or pa's and docs alternate shifts and a doc is available for backup call for the pa as needed.
I work at 1 facility of each type a few days/month. at job #1 I am double coverage during the day with a doc alternating pts. at facility #2 docs do days and pa's do solo nights.
nice arrangement all around. the facility saves money, the docs, pa's, and pts are all happy.
these are small facilities that can't afford to pay a residency trained/boarded em doc.
at facility #1 the docs make 145/hr and the pa's make 50/hr.
at facility #2 the docs make 70/hr and the pa's make 45/hr.

 

[secretwave101]

Depends on the clinic where you work. Doing extra shift work in an ED isn't going to fit in well if you take inpatient call and do OB. If you work 9-5, it's fine. But, one of the reasons rural ER's take FP's is because the work is so similar. Small ED's are pretty much an FP clinic where you don't know the patients with the occasional antler-goring and r/o MI coming in.

 

[sophiejane]

Depends on the clinic where you work. Doing extra shift work in an ED isn't going to fit in well if you take inpatient call and do OB. If you work 9-5, it's fine. But, one of the reasons rural ER's take FP's is because the work is so similar. Small ED's are pretty much an FP clinic where you don't know the patients with the occasional antler-goring and r/o MI coming in.

Or bull-horn goring, depending on the region. Don't forget lacerations sustained while castrating a calf or 3-wheeler collisions.

 

[deleted6669]

or mva's on the highway....or acute anaphylaxis....or anything you see at any other emergency dept, just in smaller #s.....
last month I flew out 2 traumas at the same time from one of these little depts....quite a sight with 1 helicopter on the pad loading the more critical pt while helicopter #2 hovered at a safe distance waiting for pt #2....

 

[f_w]

Small ED's are pretty much an FP clinic where you don't know the patients with the occasional antler-goring and r/o MI coming in.

I don't know where that assumption comes from.

If you are a small ED between right between a couple of bigger hospitals maybe, but around here hospitals are spaced at 35-50mi intervals. Whatever gets scooped up from the asphalt comes right through the door, leveled trauma ER or not. Good news is, for the really bad stuff or if you have more than 2 major traumas at the same time, the surgeon and an anesthesist come in to lend some hands and guidance. If you are lucky you have VMC (visual meterologic conditions) and one of the trauma centers will take the patients off your hands using a helicopter. Unfortunately, accidents tend to happen when it rains or snows, making transfers out a bit more challenging.

 

[deleted6669]

I don't know where that assumption comes from.

If you are a small ED between right between a couple of bigger hospitals maybe, but around here hospitals are spaced at 35-50mi intervals. Whatever gets scooped up from the asphalt comes right through the door, leveled trauma ER or not. Good news is, for the really bad stuff or if you have more than 2 major traumas at the same time, the surgeon and an anesthesist come in to lend some hands and guidance. If you are lucky you have VMC (visual meterologic conditions) and one of the trauma centers will take the patients off your hands using a helicopter. Unfortunately, accidents tend to happen when it rains or snows, making transfers out a bit more challenging.

agree- some of the worst traumas I have seen have been at little rural facilities and that's saying a lot as my primary job is at a regional trauma ctr.....

 

[f_w]

agree- some of the worst traumas I have seen have been at little rural facilities and that's saying a lot as my primary job is at a regional trauma ctr.....

Infrequent, but juicy:
- climbs of deerstand, shoots himself through femoral artery with 30-30
- falls of deerstand
- falls of deerstand
- minivan-->bicycle
- ATV into fencepost
- ATV into building
- ATV into tree
- snowmobile into fencepost
- snowmobile into building
- snowmobile into tree
- T-boned on country-road (4 level-2 trauma, 1 level-1, 1 doa)
- flipped propane tanker
- various alcohol related violence on the nearby reservation
- did I mention: falls of deerstand

 

[sophiejane]

- did I mention: falls of deerstand

 

[Mad Dog]

Interesting the focus here on trauma. Traumas can be chaotic, but really, what exactly is the responsibility of the ER physician?

Head stuff -> head CT -> neurosurgeon
Internal stuff -> FAST/belly CT -> trauma/general surgeon
Bone stuff -> plain films -> ortho

You have to be able to do the procedural stuff that anyone who works the ER should be able to do: intubations, chest tubes, lines, resuscitation, etc. Then you just ship ‘em out to a higher level of care. I mean, just cause you’re out in the sticks doesn’t mean its the ER doc’s job to take out someone’s spleen or ORIF someones tib/fib fracture.

The hard stuff is all medical, the blue baby where you haven’t a clue, the old dude with the mental status changes and 28 possible reasons why, the patient with pain and vomiting and negative imaging and labs on 10 different occasions. Being EM trained gives you a leg up with not missing something critical, but FP’s can and do work ERs with a bit of a learning curve.

 

[f_w]

Interesting the focus here on trauma. Traumas can be chaotic, but really, what exactly is the responsibility of the ER physician?

Its the high pressure and limited resources the usually lone ER provider has to deal with that make it so challenging. One thing to remember is that not only are you down to one doc, you also might only have one RN and maybe an aide or tech.
Most MVAs come with more than one victim. Most of the time, there is only one that needs the high level of attention, but at the same time someone has to have a look at the 5 collared others with 'neck pain' 'chest pain' and other trauma related complaints that clog up your rooms.

 

[Mad Dog]

Yes, I see your point.

Compare that of course to the situation in any level 2 or 3 trauma center, where there are so many people the common refrain instead is, “Can everyone not doing anything please get out of the room?”

Or compare to a dedicated level 1 trauma center, where the trauma nurses have done it so many times that the whole show pretty much runs on automatic. Then the physicians job after the primary and secondary survey gets limited to, “oh, and did you want a chest, abdomen, pelvis or just an abdomen and pelvis” as the patient is being rolled to the scanner…

I don’t like trauma because its so darn repititous. But as a general concept I think any trauma of any severity should go straight to someone who CAN do an emergent thoracotomy or emergent laparotomy if needed. That’s what saves lives. The rest of this is just basic evaluation and stabilization. Which granted though is harder when its all you!

 

[Doc Oc]

There's no such thing as an "ER-heavy residency" that I know of. .

I am a resident at an "ER-heavy residency". We are on call Q6, and spend from 5:30pm to 11pm working the the ER and functioning as an ER physician. This is in addition to our ER rotation. So, by the end of intern year, I will have worked 60 short ER shifts. I get to suture, put on splints, and if assertive, get involved in the traumas and other stuff too. Most of the 2nd and 3rd years moonlight at ERs at the rural hospitals in the area (within 1-2 hours), and it is encouraged. PM me if you have more questions.

Edit: You are on call, and any admissions that come in, you do those. You are still on call all night. You are not on call for in-house patients, just admissions and your ER shift. After 11pm, you can stay in the ER, sleep at the hospital, or go home and they will call you if there are more admits (and if I'm on, there usually are).

 

[secretwave101]

I don't know where that assumption comes from.

Sounds like your experiences have been more exciting than mine. I've worked in 4 ERs. One was small in a big city, one was the biggest ER in a small city and one in a slightly bigger city. One was a big level 1 with surgeons and specialists all over the place.

Trauma went to surgeons after we did basic ATLS.
Complicated med went to med.
Neuro went to neuro.
Lacs went to the PA (or me).

We got to be in charge of CBC's, Chem Panels, EKG's, giving vitamin R (rocephin) and ramming as many people through the head CT scanner as possible per shift. For me, other than the occasional chest tube or intubation, ER has just been FP clinic with patients I don't know.

 

[f_w]

Sounds like your experiences have been more exciting than mine.

I am talking about a reasonably busy remote rural ER (next level 2 trauma is 90miles, next level 1 is 194miles, helo-base 54miles). Here we get everything a bigger place sees, albeit at a much lower frequency.

 

[sophiejane]

We got to be in charge of CBC's, Chem Panels, EKG's, giving vitamin R (rocephin) and ramming as many people through the head CT scanner as possible per shift.

This is so true. I'm laughing, but I'm crying inside, because I'm the poor bastard whose pager goes off at 3 am with the following wealth of information from an ER doc: "Yeah, uh, we've got one of y'all's patients down here. A six year old, I think. No, wait, maybe that's the two year old. Anyway. Nausea and vomiting. Probably going to need admission. No, we haven't really done labs or anything yet, just thought we'd let y'all know so you can come see her. I mean him. Him."

 

[deleted6669]

This is so true. I'm laughing, but I'm crying inside, because I'm the poor bastard whose pager goes off at 3 am with the following wealth of information from an ER doc: "Yeah, uh, we've got one of y'all's patients down here. A six year old, I think. No, wait, maybe that's the two year old. Anyway. Nausea and vomiting. Probably going to need admission. No, we haven't really done labs or anything yet, just thought we'd let y'all know so you can come see her. I mean him. Him."

yeah, almost as good as the 5 o'clock turfs we get from fp clinic:
"fever and malaise x 2 weeks, please eval....."(note in it's entirety on one of my pts yesterday). presents with hemoptysis. 20k wbc. k=2.7. cavitary lesions on cxr.
dx: pulmonary tb.
previously seen in fp clinic 2 days prior with dx of "sinusitis". on amox without improvement.....

 

[The Janitor]

yeah, almost as good as the 5 o'clock turfs we get from fp clinic

Wrong forum, dude.

 

[deleted6669]

Wrong forum, dude.

hey, a good stupid er doc anecdote deserves a good stupid fp doc anecdote.....

 

[iatrosB]

hey, a good stupid er doc anecdote deserves a good stupid fp doc anecdote.....

agreed