us fellowship

[oldandtired]

"I have heard of an U/S felllowship where the salary is ~$70-80K, you work a number of shifts as an attending and others just scanning."


What an utter waste! Why would an ER doc want to scan patients and spend a year learning it in a fellowship?

An ER doc at most needs to know if there are stones in the gallbladder, an intrauterine pregnancy, fluid in the belly or hydro. You dont need a year fellowship for that!!!

If an ER doc wants to bill for ultrasound, they will quickly lose radiology support for more complex ultrasound scans and will collect a nickel on every dollar they bill in most places.

Dont get what the sudden fascination with ultra$$ound is? Let the experts do it? Stick to what you know best.

---

Members don't see this ad.

 

[Apollyon]

Lose radiology support? Huh? We know what we need to, and when to call for someone more specialized. I will trust my exam for pericardial effusion or cardiac standstill, but will defer to cards for a true echo. Our ultrasound director (fellowship trained) scans EVERYONE for EVERYTHING; he points out clearly when the U/S can be used in medical decision-making (like the IUP) and not (like the guy with epidydimitis).

You've gone through this rabble on other threads. In the 2004 edition of ATLS, FAST is the "F" after ABCDE. The ACS (I believe - one of the colleges/academies) has come out saying all central lines should be U/S guided. EM U/S is not going away. Your post will be regarded with the value it has.

 

[The White Coat Investor]

Stick to what you know best everyone. Don't bother trying to learn anything new, especially anything that might help your practice.

The fascination with ultrasound I am sure reared its ugly head as some EP sat around waiting for his patient to go to US, then sat around while the patient was at US, then sat around while the radiologist read the US, then sat around while the radiologist ate lunch, then sat around while the radiologist forgot about the US, then finally called the radiologist again and found out there was a gallstone. Then one day our hero put the US on some lady's gallbladder and saw the stone himself, saving himself and the patient hours of waiting. He thought, wow, I wonder what else I could learn to do with an US without doing a radiology residency? I wonder how this could change EM. The FAST was born, the US for IUP was born, the US for tamponade was born, the US for DVT was born, the US for FB was born, and the US aid for doing central lines was born. So our hero tried a few other things....they didn't work out so well. It turned out it was really hard to tell if a patient had glaucoma with an US, so he scrapped that idea. To this day, he is still trying to figure out how using the US in the ED can save him time and effort, save the patient time and money, and all without compromising patient safety. One day he said to himself, hey, this ought to be a billable procedure, so he tried billing for it. It worked. So he tried another, and it worked. Then the radiolowussies got all hot and bothered and said, well sure, you can learn to see an IUP, but look at the TOA you missed. Our hero had to admit that he wasn't that good, but that the clinical question he wanted answered was IUP or no IUP, not what's up with the pelvis. The radiolowussies backed down, but whined so much to the chief of staff of the hospital that this EP was stealing their money that they required our hero to prove he was capable. His young friend who was just learning US hadn't done quite as much, and they judged him not to be capable. So our hero set up a fellowship whereby his young friend could become capable. Thus we see the origin of the US fellowship. And every year since then, people who aren't willing to stick to what they do best, who actually believe it takes a little time to learn to do US well, who just want a little more experience, and/or have a year to kill as they try to get the EM position of their dreams, enter an US fellowship.

 

[roja]

As a late comer to EM, I didn't really care one way or the other about US. However, after exposure to our EM U/S department, I have every intention of doing a fellowship.

I have seen two pts taken straight to the OR for appy's before based on the U/S. It saved hours of time for the surgeons and for the patient, not to mention ER resources.

FAST exams are invaluable, and while IUP seems obvious, it can be misleading and requires some skill. Gall bladders also require skill as well as aortas.

I agree that soon studies will show less complications with U/S guided line placements.

And like many fellowships, the experience is not simply to learn u/s but teaches other skills: research, time management, departmental and paperwork issues.

My only regret is that I don't get more ultrasound time this year.hours

 

[oldandtired]

Out of every 1000 ER physicians, probably one has done a fellowship in US (probably less). The other 999 have no clue what they are looking at. I know from experience. Once you get into the community setting, probably fewer than 1% of ER docs will be doing US on their own.

I fear for patient's in the hands of ER docs doing US. Sure they will catch the gallbladder stones (sometimes) but how many gallbladder CAs, Liver Mets, kidneys tumors will they miss. These are all in the field of view of a typical ruq us and incidental findings are extremely common. Who will you consult in the middle of the night for tough cases. You think I am going to get up and help you?

You think radiologists are lazy and slow? How about you guys? When was the last time you examined a patient before ordering a CT? What are the criteria for NOT getting a cxr in the ER- are there any?
Stick to managing disposition, and we will stick to diagnosis.

 

[Apollyon]

If you are old and tired, then retire. You certainly aren't open minded.

Like other rads, get this through your head - we do focused exams - we DO NOT look for liver mets, Ca's of GB's, or things other than free fluid, stones, GB wall thickening, and CBD diameter. If we DO see something else, fine, but, we are looking for certain things; we say, "Do I see this?", whereas you say "What do I see?". There is a difference. Your inference that 1 person that has done an U/S fellowship knows what they are looking at, and the other 99.9% have NO idea what they are looking at is argumentative and unsubstantiated. If your facility is that weak, you should either 1. get a new job 2. just quit 3. do something about it. The option "anonymously try and start arguments online" has a utility of nil. If you would rather come in every single night, that's fine - but your aim seems to be about the billing. If you're that focused on the money, you can find cush jobs where the money from doing RUQ sonos for the 45 y/o females will just POUR in.

But don't come into our forum with your specious arguments, supported only by your cynical anecdotes. You certainly won't change any minds, and you don't help your cause.

 

[jazz]

actually apollyon sums up what we do in the er perfectly. having the ultrasound available in the er helps us answers quickly that somtimes do make a difference for patient care. for instance, at a community hospital, a teenager was dropped off by friends diaphoretic, pale, after being hit by a baseball in the abdomen. it was at night, no 24 hour CT scan, RUQ scan shows free fluid. we now know what

i have to comment however. to oldandtired: i'm not sure where you work but i never order a ct scan before seeing and examining a patient and although cxr are obtained often in the er, not nearly everyone gets it. it just seems that way when you are in a dark room reading films and never seeing patients.

i have the opposite problem with radiologists asking me for lab data (is there a white count? how tender is the patient? is the patient febrile?) sometimes before they commit to their readings. at the same time, i realize that some are better radiologists than others and i don't stereotype all radiologists as poor.

 

[Sessamoid]

Originally posted by oldandtired
You think radiologists are lazy and slow? How about you guys? When was the last time you examined a patient before ordering a CT? What are the criteria for NOT getting a cxr in the ER- are there any?
Stick to managing disposition, and we will stick to diagnosis.

This quote only shows how little clue you have about what we do in the ED. EVERY PATIENT is examined before ordering a test with significant radiation exposure and possible contrast reaction. EVERY SINGLE ONE. I have never ordered belly CT on a patient I have not examined, and I doubt many of my residency trained colleagues have ever done so either. Occasionally I send a patient for appendectomy based on clinical exam alone, and the surgeons are confident enough in my exam that they call in the OR team and book the room before even seeing the patient themselves.

If every patient in our ED got a chest x-ray, the radiologists would be reading 50,000 chest x-rays a year, just from the ER. I can assure you that that isn't the case.

I don't come to the radiology forum and **** on your profession. Don't come into ours and **** on us, especially with nothing but baseless accusations.

 

[DrQuinn]

Maybe we SHOULD order CXRs on every patient that comes in... think how much the radiologists would make! We see 70,000 a year, so that's what, $200 a pop each? Make it a PA/Lat and tack on a few bucks as well. For that matter, I might as well order a head CT on EVERY patient with a headache, I mean, it only seems like half my patients come in with a CC of headache... so that's about 35,000 head CTs to read. I will do all of this without laying a hand on my patient.

Because that's what the radiologists want, I guess. I will make that the basis of our new EM program "Pick up Chart, Order, Wait for Interpretation from Fax Machine, Dispo."

Q, DO

 

[Voxel]

Love that sarcasm, Quinn. Unfortunately there are some places where that is more a reality than you think.

Sad to say that we don't get anywhere near $200 to read a cxr. Also, most of the imaging tests ordered in the ER are not reimbursed by insurance companies, medicare or self-pay patients. So while you that ordering all those tests is good for the hospital and radiologist, in fact many times we get nothing of reading the study. In fact many times this is simply due to an improperly filled out requisition form which says r/o this or r/o that without giving any clinical symptoms or pe signs.

And when I am an attending you can order all the head CTs you want Quinn. Just make sure you fill out the req properly and we'll all be happy. We'll get a real history and physical exam findings. This will make the interpretation of the imaging test more meaningful and allow us to get reimbursed for performing the interpretation.

Hey I understand there is pressure on you to see alot of patients, many of whom are high acuity but take please the extra 15 seconds to add some pertinent and reimbursable info .

 

[edinOH]

Originally posted by Voxel
Love that sarcasm, Quinn. Unfortunately there are some places where that is more a reality than you think.

Sad to say that we don't get anywhere near $200 to read a cxr. Also, most of the imaging tests ordered in the ER are not reimbursed by insurance companies, medicare or self-pay patients. So while you that ordering all those tests is good for the hospital and radiologist, in fact many times we get nothing of reading the study. In fact many times this is simply due to an improperly filled out requisition form which says r/o this or r/o that without giving any clinical symptoms or pe signs.

And when I am an attending you can order all the head CTs you want Quinn. Just make sure you fill out the req properly and we'll all be happy. We'll get a real history and physical exam findings. This will make the interpretation of the imaging test more meaningful and allow us to get reimbursed for performing the interpretation.

Hey I understand there is pressure on you to see alot of patients, many of whom are high acuity but take please the extra 15 seconds to add some pertinent and reimbursable info .

Wait a minute. Let me see if I have this straight. You mean to tell me that there are pts. who are seen in the ED who either can't or won't pay their bills? Man, that sucks.

One thing I have noticed is that usually it is the tech or clerk who is actually filling out the req form. I've seen where I write the order for the study with a sentence describing c/o and or what we are concerned about then I look at the req sheet the radiologist gets and it says something like "arm pain" when in fact it should say "FOSH/snuff box ttp". I can imagine your frustration.

 

[EMIMG]

Personally, I think that the use of ultrasound by EPs is something this is incredibly exciting, and provides an intense benefit for patients. Yes, there are some physicians that will miss things; however, by in large, the patients will have positive outcomes. EPs are not radiologits, nor will any insist that they have as mouch training as them; howevever, they can become proficient at using ultrasound as an aid in diagnosis.

For example, ultraound has been shown to change the course of a patient's treatment by being able to find a fluid collection under what may have just been considered a "cellulitis."

Ultrasound has been used to aid in the drainage of peritonsillar abscesses so patients don't need to be blindly stuck for drainage.

EPs and nurses use ultrasound for the guidance of IV access in both periphery as well as central venous access and the people that benefit are the patients.

Being able to rule out a DVT in a patient prevents the patient from having to be started on anti-coagulation, and be admitted to the hospital for further anticoagulation and possible side effects of bleeding until the DVT can be ruled out.

Having the EP be able to diagnose the AAA can allow earlier surgical intervention so the patient may have a better prognosis.

As for the radiologists being experts in reading US, check out the following link where an EP, who is proficient in the utilization of ultrasound was able to raise the index of suspicion for an ectopic enough to get a patient to the OR despite having the radiologist read the US as being "normal"

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8B-466PVH5-B&_coverDate=05%2F31%2F2002&_alid=130660774&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=5082&_sort=d&view=c&_acct=C000012179&_version=1&_urlVersion=0&_userid=147018&md5=0fc77f3883323cee1d48e377169583c3

These are just a few instances of where EPs have effectively used US to aid in the diagnosis of patient complaints. They can use it as an adjunct and "correlate clincally" at the bedside.

For those people that still have hesitations about EPs being able to interpret and bill for US, it is similar to the war that happened in the past between cardiology and EPs. Currently EPs interpret and bill for EKGs because they must treat based on the interpretations they make....similar to how they use ultrasound.

Just my 2 cents.

 

[ERMudPhud]

Why is it that every few months a radiologist (resident?) gets pissed at the ER for ordering too damn many studies for him to read and starts posting trolls in the EM forum?

Most EM physicians will never do an U/S fellowship but more and more of us are using it and its saving time and lives. I can't even get a radiology US after 10pm and I've sent more than one ruptured ectopic or leaking AAA to the OR based on my scan alone. (granted, one turned out to be a ruptured corpus luteum cyst but she was still unstable, bleeding, and needed to go to the OR) The people doing the fellowships aren't likely to go to work in the community and steal your studies. They are going in to academics and will make sure that future EM physicians are even better at US. The future and present of US is that radiology doesn't own it. OB/Gyn, EM, Surgery, Anesthesia, Cardiology, Critical care and probably others are all using it for their own purposes. Now if your going to piss on us, my list of radiology pet peeves.

1. Don't fax me a report or tell me to check the dictation. Every other physician I consult discusses the case with me, why can't you? I have to read all the plain films myself anyway and the radiologist isn't overreading them for potentially 24 hours (long after most clinical decisions have been made). The least you can do is discuss the more complicated studies with me.

2. If you wan't to know lab results or exam findings at least explain why they will change your interpretation. We all have seen appy's with normal CBC's so if you see an inflammed appy go ahead and say so. If you can't see anything and the study is equivocal then say so.

3. Don't tell me one thing and dictate something else.

4. If the study is suboptimal than say so. More than once when speaking to a radiologist who called to report a negative study, I said I was pretty damn sure what the patient had and how confident were they in their interpretation. At that point the radiologist said, " well the truth is there is a lot of motion artifact and it really is a pretty crappy study"

Thanks for helping us take care of our patients, we honestly couldn't do it without you but just 'cause you got crushed by the ED last night is no reason to come pissing on us now. If your ED is like mine than for every CT you had to read I probably had to take care of 10 or 20 patients.

 

[Whisker Barrel Cortex]

I understand the quick use of ultrasound for urgent cases, especially when radiology is not available (it is available at every hospital I have seen 24/7). However, I still feel a confirmatory ultrasound or "complete" exam should be performed at some point after the initial ER ultrasound or things will be missed. And not just incidental findings.

As for ER doctors "always" seeing patients before ordering a study, I gotta say thats wrong, even at a University Hospital such as my own. On call, when not busy, I have actually gone to the ED to see some patients since the provided history was something like "pain" and I needed further history to clear up some confusing findings on x-ray. On several occasions, I was the first MD to see the patient. I saw one kid in the waiting room! I haven't seen CTs ordered without seeing the patient, but I have seen them ordered with little thought as to what the actual diagnosis could be. The reason I know this is when I ask the ED physician about the patient he knows very little about them and has no real theory as to the cause of symptoms.

Getting clinical history such as physical exam findings, brief h/o symptoms, and pertinent labs is critical for radiologists, who are physicians and make decisions based on the full picture. Radiologic exams are not cut and dry many times and many findings can be seen in multiple conditions. With no clinical input, all we can provide is a list of differentials with no commitment, which is what clinicians complain about in the first place. With history, we can commit to an answer much more readily.

As for clerks putting in indications wrong, have you thought of talking to them and asking them to put everything you wrote down onto the requisition. Put that in their orietation packet. Just some suggestions.

 

[Sessamoid]

Originally posted by Whisker Barrel Cortex

As for ER doctors "always" seeing patients before ordering a study, I gotta say thats wrong, even at a University Hospital such as my own.

I did not say all patients were seen before any "study" was ordered, only CT. Plenty of patients get a quick order for an x-ray based on obvious complaint. AIDS patient with a fever and coughing will often get a chest x-ray ordered from triage, which I think is completely appropriate. It speeds the information gathering process, and it's a no-brainer to order even for nurses. Another example is the patient with a h/o FOOSH with obvious deformity getting both wrist and hand x-rays before the physician sees him.

I haven't seen CTs ordered without seeing the patient, but I have seen them ordered with little thought as to what the actual diagnosis could be.

So you agree with me. As for wanting more clinical information, feel free to call or even come down and ask.