what's your take on combined EM/IM

[BMW19]

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Hey guys,

Thought I'd get your opinions on EM/IM combined. Do they adequately prepare one to be both? Would it open up more opportunities or just add another year to your training.

BMW-

 

[12R34Y]

It would add another 2 years to your training. they are all 5 year programs.

 

[BMW19]

I was assuming a 4 year EM program since I am a DO student.....

It would add another 2 years to your training. they are all 5 year programs.

 

[DropkickMurphy]

I'm actually planning on doing an EM/IM or EM/Peds combined residency. I just think it makes sense. I'm also planning on looking into the Henry Ford EM/IM/Pulmonary CCM 6 year program (which is the ONLY reason I would apply to Ford's EM residency since you have to be a PGY1 EM resident to apply for the combined program). Now if someone would start an EM/Peds/CCM program, I'd sell my soul.....

 

[12R34Y]

I was assuming a 4 year EM program since I am a DO student.....

If you did a osteopathic internship and then wanted to do EM/IM wouldn't you still have to do the 5 year combined program and thus wouldn't it be 6 years?

I seriously don't know.

 

[MD Dreams]

Is there something about Henry Ford we should know? Just curious because its one of the programs I'm considering applying to. Thanks.

 

[AmoryBlaine]

Hey guys,

Thought I'd get your opinions on EM/IM combined. Do they adequately prepare one to be both? Would it open up more opportunities or just add another year to your training.

BMW-

From what I've heard (small sample size), graduates end up doing one or the other (almost always EM).

 

[bulgethetwine]

Is there something about Henry Ford we should know? Just curious because its one of the programs I'm considering applying to. Thanks.

I have absolutely NO vested interest since I'm a resident in the southeast, but I would wholeheartedly endorse Henry Ford. Great PD, awesome pathology... good combined programs if that's your interest, but I would caution against the individual who stated he/she was only going to apply to the place for the combined. Their EM residency is top notch. Yeah, tough weather climate in the winter, prob the biggest negative.

 

[bartleby]

This question has been addressed before (search above), but at the risk of doing a complete retread, I'll try to hit a couple of high points.

In my experience, while there is comfort in the pathway to dual board certification (i.e. "keeping my options open"), I've never met any EM/IM or graduate who does anything but EM. Why? Because if you're in an EM group with defined work hours and no call, why would you want to work in a clinic or as a hospitalist for less money and longer work hours?

If you're thinking about an escape plan from EM, the extra two years of residency would be better of spent working and banking the extra $250-300k that you'd make over resident salary for two years (conservatively). If you invest that money over even a 20 year, you're well on your way towards an early retirement nest egg. Do you really see your self joining an IM group for a pay cut with extra hours, taking call, and being the "junior guy" in a group at the age of 50? Golden parachute my arse...

If you find yourself tiring as you age, you're better off working even half time (which may still amount to ~$100k/yr in many jobs) or even leaving medicine entirely for another career rather than trying to hedge your bets with IM.

 

[DropkickMurphy]

Is there something about Henry Ford we should know? Just curious because its one of the programs I'm considering applying to. Thanks.

No not at all, I've worked with a graduate of their program and it's a great program. I just don't like the idea of being in Detroit for an extended period of time. It isn't the greatest place to live.

 

[8744]

...In my experience, while there is comfort in the pathway to dual board certification (i.e. "keeping my options open"), I've never met any EM/IM or graduate who does anything but EM. Why? Because if you're in an EM group with defined work hours and no call, why would you want to work in a clinic or as a hospitalist for less money and longer work hours? ...

Same with those puzzling combined Emergency Medicine/Family Medicine programs being contemplated which, as they are going to be five years long, will save you one year geting a board certification in a specialty which involves things most people do Emergency Medicine to avoid...i.e. continuity of care and really, really getting all into Mrs. Smith's bunions over the course of a fifteen year relationship.

Now, I can understand a thirst for knowledge driving someone to combine IM with EM. But FM? Whats the angle? Will these pograms be less competative than staight EM? Is there a demand for this kind of thing?

 

[ElZorro]

I also can understand, in theory, why someone would do a combined program. However, practically it doesn't make a lot of sense (see above). Additionally, it seems that in order to be a good EM doc you must be acting as a poor IM doc, and vice versa. A large part of your EM training is learning how to discriminate b/t life threatening and correctable vs non-acute or non-lifethreatening and / or incorrectable. This is a vital skill for an EM physician, because we are all about keeping pts flowing through the ED so nobody dies of ischemic bowel in the waiting room (and so everybody makes money). However, in IM, their philosophy is to get to the bottom of everything. Your chromium is low- lets run IV chromium and do 24 hr chromium studies to calculate the fractional excretion, and maybe we should do a bowel study to look at absorption in the gut. This is an amazing difference in approach b/t the two areas, and I think it would be hard to come out of a combined residency practicing one day as an efficient EM doc and the next day as a incredibly detail oriented IM doc. It could probably be done, but I think it would make my head hurt trying to constantly ignore my urge to move the pt faster.

 

[turtle md]

We have 3 EM/IM grads every year. This year, 1 is going EM, 1 is going nephro, and 1 is going out-pt medicine. I asked one of the 2nd year combined why, and his angle was, since he wants to do academics, and everyone needs a niche, his will be IM. I didn't get it, but nodded politely anyway.

BTW - I am now officially DONE w/ the medicine dept. No more med months, EVER!!! The only time I'll see those people again is to admit to them...

 

[turtle md]

I also can understand, in theory, why someone would do a combined program. However, practically it doesn't make a lot of sense (see above). Additionally, it seems that in order to be a good EM doc you must be acting as a poor IM doc, and vice versa. A large part of your EM training is learning how to discriminate b/t life threatening and correctable vs non-acute or non-lifethreatening and / or incorrectable. This is a vital skill for an EM physician, because we are all about keeping pts flowing through the ED so nobody dies of ischemic bowel in the waiting room (and so everybody makes money). However, in IM, their philosophy is to get to the bottom of everything. Your chromium is low- lets run IV chromium and do 24 hr chromium studies to calculate the fractional excretion, and maybe we should do a bowel study to look at absorption in the gut. This is an amazing difference in approach b/t the two areas, and I think it would be hard to come out of a combined residency practicing one day as an efficient EM doc and the next day as a incredibly detail oriented IM doc. It could probably be done, but I think it would make my head hurt trying to constantly ignore my urge to move the pt faster.

You mean you don't deal, on a daily basis, with chromium in the ED? 😕 I am confused, I thought that was what we did...

 

[AmoryBlaine]

This question has been addressed before (search above), but at the risk of doing a complete retread, I'll try to hit a couple of high points.

In my experience, while there is comfort in the pathway to dual board certification (i.e. "keeping my options open"), I've never met any EM/IM or graduate who does anything but EM. Why? Because if you're in an EM group with defined work hours and no call, why would you want to work in a clinic or as a hospitalist for less money and longer work hours?

If you're thinking about an escape plan from EM, the extra two years of residency would be better of spent working and banking the extra $250-300k that you'd make over resident salary for two years (conservatively). If you invest that money over even a 20 year, you're well on your way towards an early retirement nest egg. Do you really see your self joining an IM group for a pay cut with extra hours, taking call, and being the "junior guy" in a group at the age of 50? Golden parachute my arse...

If you find yourself tiring as you age, you're better off working even half time (which may still amount to ~$100k/yr in many jobs) or even leaving medicine entirely for another career rather than trying to hedge your bets with IM.

👍

The few people (all M1/2s) who I have talked to who want to do EM/IM all have the same idea. They want to work "2 or 3 shifts" per week in the ED and then have an outpatient clinic where they can follow up with people they saw during their shifts. I always listen politely, and try not to do an impersonation of Dr. Evil saying, "riiiiiiiiiiiiiiight."

It does seem (to this ignorant M3) that a dual board in EM/IM certainly couldn't hurt you in the ED, but that it wouldn't help you much at all in the IM (especially outpatient) setting. Thoughts?

 

[Tusk]

This question has been addressed before (search above), but at the risk of doing a complete retread, I'll try to hit a couple of high points.

In my experience, while there is comfort in the pathway to dual board certification (i.e. "keeping my options open"), I've never met any EM/IM or graduate who does anything but EM. Why? Because if you're in an EM group with defined work hours and no call, why would you want to work in a clinic or as a hospitalist for less money and longer work hours?

If you're thinking about an escape plan from EM, the extra two years of residency would be better of spent working and banking the extra $250-300k that you'd make over resident salary for two years (conservatively). If you invest that money over even a 20 year, you're well on your way towards an early retirement nest egg. Do you really see your self joining an IM group for a pay cut with extra hours, taking call, and being the "junior guy" in a group at the age of 50? Golden parachute my arse...

If you find yourself tiring as you age, you're better off working even half time (which may still amount to ~$100k/yr in many jobs) or even leaving medicine entirely for another career rather than trying to hedge your bets with IM.

Nice post. Makes a great case for only following an EM path.

 

[BMW19]

So much for the dual residency, EM here I come!!

BMW-

 

[WilcoWorld]

Y'all are missing one motivating factor that has a MAJOR influence on many, if not most, people in the medical profession: Ego

Being double boarded is like the Porsche of academic medicine. But I drive a Honda, so what do I know?

 

[emtp6811]

Now, I can understand a thirst for knowledge driving someone to combine IM with EM. But FM? Whats the angle? Will these pograms be less competative than staight EM? Is there a demand for this kind of thing?

I know someone who is hoping to apply to an EM/FM residency because he wants to work in a very rural area where he would essentially be the only doctor for about 2-3 hours drive, and ~1 hour helicopter. He figures he would be better prepared to take care of both urgent and non-urgent needs with this background.

 

[AmoryBlaine]

Y'all are missing one motivating factor that has a MAJOR influence on many, if not most, people in the medical profession: Ego

Being double boarded is like the Porsche of academic medicine. But I drive a Honda, so what do I know?

Is it really? I have never heard this before. I would think publications and authorships would be the Porsche of academic medicine much more than double boards. I mean, I wouldn't think board certification in IM would do much to impress your fellow EM docs (and vice versa).

 

[DropkickMurphy]

I know someone who is hoping to apply to an EM/FM residency because he wants to work in a very rural area where he would essentially be the only doctor for about 2-3 hours drive, and ~1 hour helicopter. He figures he would be better prepared to take care of both urgent and non-urgent needs with this background.

I've said (half-jokingly) that the only reason for my doing double boards in EM and IM is so that I can have admitting privileges in case one of my friends or family needs admitted and I want to manage the case to its conclusion.

 

[bulgethetwine]

I've said (half-jokingly) that the only reason for my doing double boards in EM and IM is so that I can have admitting privileges in case one of my friends or family needs admitted and I want to manage the case to its conclusion.

Well, you can be whole joking now -- most centers won't let you admit to yourself. Billing reasons, of course! 😳

 

[bartleby]

Please don't misinterpret this post...I have a lot of respect for our IM colleagues. Owning up to a patient with depression, fibromyalgia and borderline personality disorder AND taking good care of him/her requires a pain threshold well beyond me. But when it comes to situations like International EM, you're much more in the purview of EM. You aren't ordering PET scans and urine & serum protein electrophoresis in St Lucia or Namibia. You're doing it quick, dirty and cheap (just how I like it). That's what we're already good at.

I understand the desire to be THE doctor. But in modern western medicine, no man or woman is an island. We're all just cogs in the great noble healing machinery. Mouthy subspecialists who don't have that kind of perspective when woken out of a sound sleep at 3am can be forgiven, but it's the truth. Having said that, when the flight attendant calls overhead for a doctor in a plane an hour from the nearest airport, nobody's hoping that an endocrinologist is on the plane. They want YOU.

Modern medicine is such an extensive body of knowledge that its entirety is unknowable to any one person. Hell...any THREE people.

I'm very interested in doing international work in the future and I thought maybe an EM/IM combination would best prepare me for anything out there.

The only thing more foolhardy than a doctor trying to take care of himself is a doctor trying to take care of family. Your judgement depends on a certain clinical detachment. Otherwise, you either overtreat not wanting to miss anything or undertreat counting on the improbable best case scenario not wanting to believe that the worse is happening to your loved one. Find a good colleague and give them your trust. Both you and your family will save a great deal of heartache.

I've said (half-jokingly) that the only reason for my doing double boards in EM and IM is so that I can have admitting privileges in case one of my friends or family needs admitted and I want to manage the case to its conclusion.

 

[paramed2premed]

Hey guys,

Thought I'd get your opinions on EM/IM combined. Do they adequately prepare one to be both? Would it open up more opportunities or just add another year to your training.

BMW-

One very small advantage - you would be able to become boarded in critical care medicine. Can't do that with "just" EM.

Personally, I don't know what it is about all those hours spent in clinic that specially prepare IM folks for critical care, but that's a different topic.

 

[jashanley]

This question has been addressed before (search above), but at the risk of doing a complete retread, I'll try to hit a couple of high points.

I've never met any EM/IM or graduate who does anything but EM. Why? Because if you're in an EM group with defined work hours and no call, why would you want to work in a clinic or as a hospitalist for less money and longer work hours?

Some graduates go onto fellowship in IM. Our 5th yr is doing cardiology. I am awaiting the match in Pulm/CCM and one of our second years wants to do cards as well. We have had several grads do CCM alone and practice CCM solely. I hate when people make blanketed statements about something they are not involved in directly. Yes, most graduates do EM, specifically academic EM, but some do fellowships. Very few do IM alone. Those doing IM, are usually working with a combined program in some capacity.

 

[12R34Y]

Some graduates go onto fellowship in IM. Our 5th yr is doing cardiology. I am awaiting the match in Pulm/CCM and one of our second years wants to do cards as well. We have had several grads do CCM alone and practice CCM solely. I hate when people make blanketed statements about something they are not involved in directly. Yes, most graduates do EM, specifically academic EM, but some do fellowships. Very few do IM alone. Those doing IM, are usually working with a combined program in some capacity.

sounds kind of like what bartleby said. right?

you said yourself at the end that "yes, most graduates do EM......few do IM alone."


I think that's what he was getting at. Most do EM only.

Unless you're the infamous KGUNNER who does EVERYTHING ALL OF THE TIME!

 

[Hard24Get]

Some graduates go onto fellowship in IM. Our 5th yr is doing cardiology. I am awaiting the match in Pulm/CCM and one of our second years wants to do cards as well. We have had several grads do CCM alone and practice CCM solely. I hate when people make blanketed statements about something they are not involved in directly. Yes, most graduates do EM, specifically academic EM, but some do fellowships. Very few do IM alone. Those doing IM, are usually working with a combined program in some capacity.

Can we expand upon why EM/IM is great for academic medicine? I was hoping to go to a strong research institution for my residency but many of them don't have dual programs? 😕 Why would this be if they value it so?

 

[PimplePopperMD]

My take on it:

Glad I'm doing it. I believe that what I learn in one specialty does complement my skills in the other specialty. I would get bored, SO BORED! in just EM, and the same goes for IM. I'm really looking forward to switching back to medicine in July, and at the end of my three month block, I'll be looking forward to the switch to EM.

True that most do EM afterward. So what? There are some who are practicing both, generally at academic centers. Not terribly conducive to clinic work, but certainly to some months as ward attending or hospitalist. A number from my program are continuing on to critical care as well.

The catch to deciding whether EM/IM is for you is the idea that you actually like both specialties, and you're not doing it for some other reason "ie i wanna be a better EM doc, or I wanna do a critical care fellowship"... it's a long haul, and you have to enjoy going to work. Although in some sense residency is a means to an end, it is also essentially what you've chosen as your vocation, and for a half a decade, you'll be living the dream.

I always suggest to applicants who come through that if they're applying for EM/IM to buff their resume, with the intention of pursuing only EM, they should withdraw their application. (also, these aren't the applicants we'd rank anyway)

 

[Dr.Evil1]

No not at all, I've worked with a graduate of their program and it's a great program. I just don't like the idea of being in Detroit for an extended period of time. It isn't the greatest place to live.

Hey that is a cheap shot. Who wouldn't love this town? Best MLB team in the US right now. You guys can't get scared away because of a little snow could you?

I don't think that you can admit a patient to yourself nor could you realistically see patients that you discharged from the ED. Hopefully they would have their own PCP and would go see that person. Otherwise why would they bother following up with you in your clinic when they could just come see you in the ED again.

 

[DropkickMurphy]

You guys can't get scared away because of a little snow could you?

I'm moving to Saginaw next May. I'm not 100% certain, but pretty sure that they get more snow than Detroit. My problem with the city involves the fact that, well to quote my friend Tyshon: "I wouldn't walk around that town with an AK, them people is nuts up there."