Why are combined FM/EM residencies not more common?

[Vivid_Quail]

Currently, there are only 3 FM/EM programs (5 years) in the country. Why are these programs not more common?

To a naive med student, dual board certification in FM and EM seems to create the ultimate rural doctor, and something like this pathway is what other large countries with remote areas do, see Australia and Canada. With FM/EM, you can legally and practically find work as a hospitalist with an open ICU, in any ED, and start your own outpatient clinic (not just urgent care). The main reason I think this is not very common is that currently FM can work inpatient, outpatient, and in the ED, so why add an extra 2 years of residency?

Maybe I am underestimating FM training but I can't imagine being comfortable handling critically ill patients (trauma or medical) directly out of FM residency. Also, with the EM job market getting worse and worse, I can see FM-trained doctors getting pushed out of the ED in the next 10-20 years. On the other hand, if you only do EM to get that trauma and CC training, you don't have the option to "slow down" and do outpatient or have a more regular sleep schedule with a 7 on 7 off hospitalist gig. Also, FM brings much more OB and peds experience to the table than EM.

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[VA Hopeful Dr]

Because it's an extra 2 years for "maybe I'll do this in the future" or "maybe I'll go work rural".

 

[Sardonix]

Because you only have so much time in life to focus on and become well versed in so many things. Sure, it would be amazing if every FM or EM physician could get all that training, but if you're an EM who will never do outpatient or an FM who will never do EM it's just more years of training/resident wages for no reason. Hell, EM residents in my experience HATE 4yr EM programs because the extra year of training is seen as unnecessary.

I mean don't get me wrong, more education and training is nice. And there are certain physicians who really DO want that experience. But they're limited in numbers and the number of EM/FM programs reflect the demand. At some point it's just time to start actual practice instead of being an underpaid resident.

 

[Vivid_Quail]

Because you only have so much time in life to focus on and become well versed in so many things. Sure, it would be amazing if every FM or EM physician could get all that training, but if you're an EM who will never do outpatient or an FM who will never do EM it's just more years of training/resident wages for no reason. Hell, EM residents in my experience HATE 4yr EM programs because the extra year of training is seen as unnecessary.

I mean don't get me wrong, more education and training is nice. And there are certain physicians who really DO want that experience. But they're limited in numbers and the number of EM/FM programs reflect the demand. At some point it's just time to start actual practice instead of being an underpaid resident.

That makes sense. The only caveat I would add is that 4 year EM programs give you nothing material in return for that extra year, so it probably feels especially wasteful. FM/EM gives you dual board certification and much more career flexibility.

 

[deleted87716]

Most people either want to do one or the other. The number of people who want to do both isn't as high as SDN would lead you to believe.

 

[EMTAB]

Most people either want to do one or the other. The number of people who want to do both isn't as high as SDN would lead you to believe.

I'll second this! I really wanted to do rural EM and found a FM program with a ton of EM exposure to allow it, but most of my friends applying wanted bread and butter FM and looked at programs with less inpatient training and a greater focus on outpatient.

 

[Vivid_Quail]

I'll second this! I really wanted to do rural EM and found a FM program with a ton of EM exposure to allow it, but most of my friends applying wanted bread and butter FM and looked at programs with less inpatient training and a greater focus on outpatient.

Do you worry about the EM job market? ABEM BC/BE doctors can't find jobs anywhere and FM doctors who have worked in the ED for decades are getting fired from ED's in suburbs because they aren't EM-trained. The benefit of FM of course is that if you can't find an FM job, you can still do outpatient or hospitalist work, unlike an EM trained person who can't find work outside ED/urgent care without a fellowship.

 

[EMTAB]

Do you worry about the EM job market? ABEM BC/BE doctors can't find jobs anywhere and FM doctors who have worked in the ED for decades are getting fired from ED's in suburbs because they aren't EM-trained. The benefit of FM of course is that if you can't find an FM job, you can still do outpatient or hospitalist work, unlike an EM trained person who can't find work outside ED/urgent care without a fellowship.

Absolutely worry about this. I think the explosion in EM residencies is scary and that's what shifted me from applying EM. I wanted to do EM, but also enjoyed FM, and thought about being a hospitalist too. I still see a lot of jobs in more rural areas for level 3/4 hospitals/ critical access hospitals that take FM boarded docs. Some are in cities of 70K+ and that's my kind of target area. As long as it has a Costco/Sam's club, a Walmart or target I'm good, but lots of EM boarded docs don't want to go to these places.

 

[Leonthemedico]

Em and FM are two separate specialties. There is some overlap and I think you can be a hybrid em/fm doctor but it takes a lot of learning to be really good. If you can do it you might as well become a surgeon and make 3x the money with the same effort.

 

[Vivid_Quail]

Em and FM are two separate specialties. There is some overlap and I think you can be a hybrid em/fm doctor but it takes a lot of learning to be really good. If you can do it you might as well become a surgeon and make 3x the money with the same effort.

Lol surgeons aren't making 3 times the money working 40 hours week, which you can definitely do in an EM/FM combo. Most surgeons don't even make double of what you can make in FM/EM ($300k) and they work 50-70 hours/week versus like 35-40 hours in EM or FM.

Literally thousands of FM docs in the US and Canada do a hybrid like this and aren't bad doctors...I am just interested in FM/EM because I want to be prepared from day one as an attending, not learn a ton as I go in a rural ED/hospital and put patients at risk. It does take a lot of learning to be really good...that is the point of adding two years of residency. (Of course there will be a lot of learning on the job as an attending even if we did 20 PGY years.)

Also surgery doesn't have nearly the breadth of FM/EM. General surgery without fellowship is the most broad field of surgery and that is going to do bread and butter abdominal cases in a rural area and then ship anything more complex. Not everything is about money + effort...you actually have to enjoy the work and find it interesting

Oh and to preemptively stop the "you can't get good at these specialties only working 20 hours per week in each." So is the standard contract of 120 hours/month of EM not enough? Are EM docs that work 80 hours/month grossly incompetent after a few years of being out of residency? Come on.

 

[Sardonix]

That makes sense. The only caveat I would add is that 4 year EM programs give you nothing material in return for that extra year, so it probably feels especially wasteful. FM/EM gives you dual board certification and much more career flexibility.

Agreed.

Lol surgeons aren't making 3 times the money working 40 hours week, which you can definitely do in an EM/FM combo. Most surgeons don't even make double of what you can make in FM/EM ($300k) and they work 50-70 hours/week versus like 35-40 hours in EM or FM.

Literally thousands of FM docs in the US and Canada do a hybrid like this and aren't bad doctors...I am just interested in FM/EM because I want to be prepared from day one as an attending, not learn a ton as I go in a rural ED/hospital and put patients at risk. It does take a lot of learning to be really good...that is the point of adding two years of residency. (Of course there will be a lot of learning on the job as an attending even if we did 20 PGY years.)

Also surgery doesn't have nearly the breadth of FM/EM. General surgery without fellowship is the most broad field of surgery and that is going to do bread and butter abdominal cases in a rural area and then ship anything more complex. Not everything is about money + effort...you actually have to enjoy the work and find it interesting

Oh and to preemptively stop the "you can't get good at these specialties only working 20 hours per week in each." So is the standard contract of 120 hours/month of EM not enough? Are EM docs that work 80 hours/month grossly incompetent after a few years of being out of residency? Come on.

... but maybe tone it down by 20% there, we're all friends here.

 

[Aheadbyacentury]

Im surprised Family Practice is not more popular.. You can literally do anything with that residency and tailor make your practice whatever you want and to boot, you do not have to rely on the hospital..

 

[Reboa]

With all of the doom and gloom in em currently it may be time to push our boards to have a reciprocal agreement with em. Recognize our em fellowships and we’ll open a path for fm certification in return.

 

[VA Hopeful Dr]

With all of the doom and gloom in em currently it may be time to push our boards to have a reciprocal agreement with em. Recognize our em fellowships and we’ll open a path for fm certification in return.

With all the doom and gloom in EM why would anyone want to have a pathway into it?

 

[Sardonix]

With all the doom and gloom in EM why would anyone want to have a pathway into it?

Honestly giving EM a lifeboat into FM wouldn't be such a bad idea, in my mind. Don't see why any FMs would go the other direction like you said, but it would only be fair for it to be a two way street don't ya think?

 

[deleted87716]

Honestly giving EM a lifeboat into FM wouldn't be such a bad idea, in my mind. Don't see why any FMs would go the other direction like you said, but it would only be fair for it to be a two way street don't ya think?

Why...? They aren't trained in primary care. Sure, they see a lot of basic primary care crap in the ED, but they don't have to manage it longitudinally. Big difference between doing primary care and sending somebody out after determining they aren't going to die right then.

 

[InternistDO]

Everyone talks about this but I believe the ABMS is quite clear that you cannot make a fellowship that gives you board certification in an existing primary specialty. The best anyone could do is give EM credit for intern year and have them do FM in 2 years.

 

[Sardonix]

Why...? They aren't trained in primary care. Sure, they see a lot of basic primary care crap in the ED, but they don't have to manage it longitudinally. Big difference between doing primary care and sending somebody out after determining they aren't going to die right then.

I'm not thinking of letting them literally just start practicing as FMs, but a pathway as you mentioned above. Could be a board exam or a year of retraining, I dunno. Just something that demonstrates competency in primary care. There are plenty of FM job opportunities and I'd rather they be filled by physicians than the other option.

Just spitballin' here. Not married to the idea.