Are family medicine residents trained enough for ER and Hospitalist work?

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psychMDhopefully

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So I've been browsing family medicine residency curricula. Usually FM residencies have about 2-3 months of inpatient medicine for 1st of 3rd year, they have 2 or 3 ER months in either year. So, is this training enough to be confident doing hospitalist or ER work? Most FM curricula have residents bounce around to a different rotation every month, I feel like there is no time to solidify any knowledge if you are in a different rotation every month. Also what is the purpose of a one month rotation? What could you become proficent in one month ortho, or derm rotation?
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It takes time but eventually you catch on and you'll be fine.
Should be ready to be a hospitalist. ER should be fine but I don't know many workin in trauma 1s.
 
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In one month, you learn what you can and should handle on your own, and when you should refer. I can do my own steroid knee injections or order my own physical therapy, for instance, but if patients fail that, then they need to see ortho for Synvisc or a knee replacement. Based on my short time with ortho, I also know who is a good candidate for a replacement and who is not.
 
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Doctor4Life1769 said:
How much does it cost?
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One course of Euflexxa (the only one my supplier carries) is $971 - that's 3 injections which is what a single knee on 1 patient gets.

By contrast, a 10mL vial of Kenalog 40mg/mL, is $68 - that's enough for 5 knees.
 
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VA Hopeful Dr said:
One course of Euflexxa (the only one my supplier carries) is $971 - that's 3 injections which is what a single knee on 1 patient gets.

By contrast, a 10mL vial of Kenalog 40mg/mL, is $68 - that's enough for 5 knees.
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No wonder only the Orthos are using them.
I thought it had to do with reimbursement and liability. Glad to know it's the cost issue at hand.
 
Doctor4Life1769 said:
No wonder only the Orthos are using them.
I thought it had to do with reimbursement and liability. Glad to know it's the cost issue at hand.
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Same thing with Botox. People always joke that I should open my own boutique practice do that I can do Botox for them.

Botox is really easy to inject. But when I did my ophtho rotation, the attending (who also did oculoplastics) said that Botox is a huge pain - once you open a vial, you have to use the whole thing in 24 hours, or else you have to toss it. Considering how much one vial costs...
 
Most of the ortho folks are using bedside ultrasound to administer joint injections (even for easy joints like shoulders and knees), which they can also bill for.
 
smq123 said:
Same thing with Botox. People always joke that I should open my own boutique practice do that I can do Botox for them.

Botox is really easy to inject. But when I did my ophtho rotation, the attending (who also did oculoplastics) said that Botox is a huge pain - once you open a vial, you have to use the whole thing in 24 hours, or else you have to toss it. Considering how much one vial costs...
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Very true.
I heard it's only beneficial to do Botox if you're doing a cosmetic only practice and it's hard to do both primary care and cosmetics together since you don't have the constant stream of patients who are exclusively for Botox. I guess it would take time if you're going to be serious about marketing both such that eventually you do get enough patients to make it worthwhile.
 
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psychMDhopefully said:
So I've been browsing family medicine residency curricula. Usually FM residencies have about 2-3 months of inpatient medicine for 1st of 3rd year, they have 2 or 3 ER months in either year. So, is this training enough to be confident doing hospitalist or ER work? Most FM curricula have residents bounce around to a different rotation every month, I feel like there is no time to solidify any knowledge if you are in a different rotation every month. Also what is the purpose of a one month rotation? What could you become proficent in one month ortho, or derm rotation?
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That's really not the question you should be asking -- well, what I mean is there is a follow on question -- let's say you do feel confident enough to work as a hospitalist or ER doc. What happens if there's a bad outcome?

In general, you will be held to the same standard as an IM hospitalist or a BC EM doc --- now think about that -- My program had us do 3 months of wards in PGY1, 6 weeks in PGY 2 and PGY3 for a grand total of 6 months of wards and 1 ICU month (during PGY2 but acting as the intern for an IM PGY2).

Now, in the IM program that was collocated with us, they did 6 months of wards and 6 months of ICU in their first year, were running ward teams/ICU teams in their second year and specialist heavy in the 3rd year -- within the first month they were signed off on all procedures to be able to do them without supervision; I think I did one central line, 1 thoracentesis, 1 PTA drain and 1 intubation during my entire residency -- for us, we always consulted the IM service to do those procedures since our attendings were not signed off on those procedures either (don't ask).

In the ER residency, they spent the first year learning medical management of whatever walked/was carried through the door at a level 1 trauma center, by PGY2 they were running the POD; heck, I saw a classmate during my OB month -- she had gone into EM and was sitting there all along repairing a post delivery lac with no supervision and doing a bang up job -- us FM schmucks (at least in my program) were over on the non-complicated delivery side with paramedics and students -- again, don't ask.

So, if it goes to court, you'll be judged by how people with that level of training would handle the case -- "I'm an FM doc, not IM" or "I'm an FM doc, not ER" won't cut it ---

For me, I can definitively say my program did NOT prepare me to be a hospitalist or an ER doc and I'm not willing to risk it.

Now, the guys that went to JPS in Ft. Worth -- they're qualified but they basically run that county hospital (or at least used to)..... did everything from ER to ICU and all points inbetween under BC attendings in each field ---

YMMV, no warranties expressed or implied.
 
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JustPlainBill said:
That's really not the question you should be asking -- well, what I mean is there is a follow on question -- let's say you do feel confident enough to work as a hospitalist or ER doc. What happens if there's a bad outcome?

In general, you will be held to the same standard as an IM hospitalist or a BC EM doc --- now think about that -- My program had us do 3 months of wards in PGY1, 6 weeks in PGY 2 and PGY3 for a grand total of 6 months of wards and 1 ICU month (during PGY2 but acting as the intern for an IM PGY2).

Now, in the IM program that was collocated with us, they did 6 months of wards and 6 months of ICU in their first year, were running ward teams/ICU teams in their second year and specialist heavy in the 3rd year -- within the first month they were signed off on all procedures to be able to do them without supervision; I think I did one central line, 1 thoracentesis, 1 PTA drain and 1 intubation during my entire residency -- for us, we always consulted the IM service to do those procedures since our attendings were not signed off on those procedures either (don't ask).

In the ER residency, they spent the first year learning medical management of whatever walked/was carried through the door at a level 1 trauma center, by PGY2 they were running the POD; heck, I saw a classmate during my OB month -- she had gone into EM and was sitting there all along repairing a post delivery lac with no supervision and doing a bang up job -- us FM schmucks (at least in my program) were over on the non-complicated delivery side with paramedics and students -- again, don't ask.

So, if it goes to court, you'll be judged by how people with that level of training would handle the case -- "I'm an FM doc, not IM" or "I'm an FM doc, not ER" won't cut it ---

For me, I can definitively say my program did NOT prepare me to be a hospitalist or an ER doc and I'm not willing to risk it.

Now, the guys that went to JPS in Ft. Worth -- they're qualified but they basically run that county hospital (or at least used to)..... did everything from ER to ICU and all points inbetween under BC attendings in each field ---

YMMV, no warranties expressed or implied.
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Thanks for your insight, if I pursue something I definitely want to be well trained for it.
 
To the OP: that doesn't seem like very good training for those types of jobs.

Like everyone is saying, a lot of it is your comfort level. If you take on the job, you have to do it 100% since the outcomes are matched as are the adverse events.

If you want to keep your options open, than consider a program that has more months in both of those since the ED is usually a "gateway" i.e. goes to obvs, med, surgery or the ICU generally.

For reference, My program has:
1. 2 inpatient months, a ccu month and an icu month, along w/ 1 peds-ED in pGY-1
2. 3 inpatient months (1/2 of it is nights by yourself) & 1 adult ED month in pgy-2
3. 2 months of inpatient in pgy-3

So close to 5 Months the first year, 4 months the 2nd year, and 2 months in the 3rd = 9 months. (I didn't include 3 months of inpatient peds).
Pretty much, 12 months out of the 36 are spent on inpatient rotations. This I felt, was the point I felt comfy to handle peds and adult inpatient, as well as peds and adult ED.
 
Also don't forget that you have plenty of elective months in residency. If you are looking at wanting to do ICU/hospitalist then do some extra months on your elective time so you do get in the procedures, managing vents, central lines, running codes, etc.

When I was fresh out of residency I did hospitalist service but don't anymore since I haven't done it in 3 years and would not presume that I am up on the latest treatments. So, yes, you can get trained to be a good hospitalist but depending on your residency it may take some personal incentive to get up to speed to be safe for the patients.
 
Hi Im an IMG FP graduate working as a hospitalist in Los Angeles, my team gave me a chance as a hospitalist since I graduated in their residency program and they knew me for doing a good work and being liked by nurses and docs. Since then, its been one year, I been loving every minute as a hospitalist, 7 days on 7 off, short days, long days, all challenging. The hospitalist path is a good option for FP but is hard to find a posiition, text me if you want more info in my program, we are always looking for FP/ IM inpatient and outpatient, other specialties welcome. Pay is well within the market and we get together every wednesday for soccer nights, is fun here!
 
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psychMDhopefully said:
So I've been browsing family medicine residency curricula. Usually FM residencies have about 2-3 months of inpatient medicine for 1st of 3rd year, they have 2 or 3 ER months in either year. So, is this training enough to be confident doing hospitalist or ER work? Most FM curricula have residents bounce around to a different rotation every month, I feel like there is no time to solidify any knowledge if you are in a different rotation every month. Also what is the purpose of a one month rotation? What could you become proficent in one month ortho, or derm rotation?
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Depends on your program. My fm residency had us do 7 months inpatient medicine first year, 6 months second. All of this including icu patients in each of those months as we had an open icu.I honestly feel more confident doing inpatient than outpatient stuff as in my program we did more inpatient more than most I'm residencies.
 
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All credentialed FM programs will provide enough inpatient experience to enable residents to competently manage hospitalized patients. Working in the ED is completely different, unless you're talking about some sort of "fast track" urgent-care type arrangement.
 
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Blue Dog said:
All credentialed FM programs will provide enough inpatient experience to enable residents to competently manage hospitalized patients. Working in the ED is completely different, unless you're talking about some sort of "fast track" urgent-care type arrangement.
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Okay, Its just that I hear a lot of IM guys saying FM doesn't prepare you for hospitalist and a lot of hospitalist job ads don't consider FM.
 
psychMDhopefully said:
Okay, Its just that I hear a lot of IM guys saying FM doesn't prepare you for hospitalist and a lot of hospitalist job ads don't consider FM.
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Of course they say that, they don't want the competition.

And you're right there are some hospitals that don't advertise for family medicine because they don't need to. We are adequately trained for Hospital medicine, but I don't think anyone of us will argue that internal medicine gets more training in that area. Whether that training makes a difference in outcomes is unclear, but it certainly looks better from a superficial standpoint.
 
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psychMDhopefully said:
Okay, Its just that I hear a lot of IM guys saying FM doesn't prepare you for hospitalist and a lot of hospitalist job ads don't consider FM.
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Most of our hospitalists trained in FM, although some are IM. We don't discriminate. As for the ads, it just depends who's doing the hiring. It has nothing to do with actual qualifications.
 
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pre med 2014 said:
I don't see why not, isn't the emergency room where you go to get primary care?

Sent from my SM-G955U using SDN mobile
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Umm, no. Yes, we see our share of primary care stuff, but even then, the way we deal with it is different than in the clinic.

We deal with codes, medically crashing patients, and trauma on a routine basis.

As for whether an FP person could work in the ER, clearly many do. However, I would strongly suggest completing an EM-fellowship after your FP residency (even though as an EM-residency trained person, I must view this as competition for my livelihood).

On the flip side, I do not think I could work in a family clinic. If ER was just PCP stuff, then clearly I would feel more confident doing so. The reality is that you should train in what field you plan on working in. If EM, then EM-residency. If FP, then FP-residency.

Of course, life is not perfect and many people opt to switch fields. My summary would be: FP to EM is doable, but not ideal.
 
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psychMDhopefully said:
Okay, Its just that I hear a lot of IM guys saying FM doesn't prepare you for hospitalist and a lot of hospitalist job ads don't consider FM.
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If you want a hospitalist job from FM you can find one. Just get boarded and take a look! I work 0.5 as a hospitalist and am approached all the time to do it elsewhere. You just have to get your foot in the door after residency and then it will click. Also, I am often the only one in the hospital besides IR that knows how to do procedures so it is actually an advantage to have FM around.
 
smq123 said:
In one month, you learn what you can and should handle on your own, and when you should refer. I can do my own steroid knee injections or order my own physical therapy, for instance, but if patients fail that, then they need to see ortho for Synvisc or a knee replacement. Based on my short time with ortho, I also know who is a good candidate for a replacement and who is not.
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What training in physical therapy do you have to "order" "my" "own" physical therapy? Interesting how physicians think they're all qualified to do that when they're not even close. Not even any observation hours of a PT, and no classes taught by a PT. Keep thinking you guys know what you don't and couldn't possibly know.
 
Fiveoboy11 said:
What training in physical therapy do you have to "order" "my" "own" physical therapy? Interesting how physicians think they're all qualified to do that when they're not even close. Not even any observation hours of a PT, and no classes taught by a PT. Keep thinking you guys know what you don't and couldn't possibly know.
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So you don't want me to order physical therapy? You don't want me to refer patients to physical therapy? You don't want me to specify how many times a week, or what the goal of therapy should be?

That's funny, because the insurance companies won't approve the referral if I don't offer some specifics.

The point of the post is to say that I don't need to refer a patient to ortho in order to order PT, not to offer PT myself with my own two hands.
 
smq123 said:
So you don't want me to order physical therapy? You don't want me to refer patients to physical therapy? You don't want me to specify how many times a week, or what the goal of therapy should be?

That's funny, because the insurance companies won't approve the referral if I don't offer some specifics.

The point of the post is to say that I don't need to refer a patient to ortho in order to order PT, not to offer PT myself with my own two hands.
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You can REFER to a PHYSICAL THERAPIST.

You're not trained or qualified to "order" specifics (i.e. Frequency or duration) or make goals. This is based on the EVALUATION that the physical therapist does. You can't do that with your joke 10 minute family medicine appointment with zero physical therapy training/classes. Maybe your "training" ought to be changed in residency to reflect the fact that the PT POC is established and supervised by the PT and not some delusions of expertise physician. Use your "insurance require it" rationale all you want but I'm not buying it as you guys only do so when it's convenient for you. I've had thousands of referrals from good doctors that respect what they're not and do not baselessly try to dictate the PT POC as if they know. I would like to lay into you in front of your state board or in a courtroom someday, hopefully I'll get the chance with you or one of your like minded colleagues with your nonsensical practice patterns.
 
Fiveoboy11 said:
You can REFER to a PHYSICAL THERAPIST.

You're not trained or qualified to "order" specifics (i.e. Frequency or duration) or make goals. This is based on the EVALUATION that the physical therapist does. You can't do that with your joke 10 minute family medicine appointment with zero physical therapy training/classes. Maybe your "training" ought to be changed in residency to reflect the fact that the PT POC is established and supervised by the PT and not some delusions of expertise physician. Use your "insurance require it" rationale all you want but I'm not buying it as you guys only do so when it's convenient for you. I've had thousands of referrals from good doctors that respect what they're not and do not baselessly try to dictate the PT POC as if they know. I would like to lay into you in front of your state board or in a courtroom someday, hopefully I'll get the chance with you or one of your like minded colleagues with your nonsensical practice patterns.
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Yeah I'm sure the state board of medical examiner cares what a PT has to say
 
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VA Hopeful Dr said:
Yeah I'm sure the state board of medical examiner cares what a PT has to say
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Maybe not but that's just a reflection of their own flagrantly poor training, zero accountability re "the PT" for years, delusions of grandeur/expertise, complete ignorance re "the PT" and antiquated beliefs, etc, etc, etc.
 
Fiveoboy11 said:
What training in physical therapy do blah blah blah Im a PT wah wah wah!!!!.
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Actually we had quite a bit of PT training in residency taught by Physical therapists, orthodocs and PCSM docs, and I rotated with PM&R docs for additional rehab training. In residency I had an excellent relationship with the good PT's in the area and I would call them after hours to go over my exam and have them confirm it with me and have them teach me finer points about their approach in diagnosis and treatment. To give the PT folks flexibility I would write "Evaluate and Treat Knee Pain", concern for patellofemoral syndrome due to blah blah blah.

Now that I am in sports fellowship I am getting rehab training on a near daily basis...Remind me not to send anyone to you, you sound terrible to work with.
 
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Fiveoboy11 said:
You're not trained or qualified to "order" specifics (i.e. Frequency or duration) or make goals. This is based on the EVALUATION that the physical therapist does. You can't do that with your joke 10 minute family medicine appointment with zero physical therapy training/classes.
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I am qualified to diagnose an inferiority complex, however...
 
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Fiveoboy11 said:
What training in physical therapy do you have to "order" "my" "own" physical therapy? Interesting how physicians think they're all qualified to do that when they're not even close. Not even any observation hours of a PT, and no classes taught by a PT. Keep thinking you guys know what you don't and couldn't possibly know.
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Interesting generalization going on here -- my residency had 2 months of orthopedics which included 2 days a week, all day for 2 months rotating with the PT program at UTSW, plus a required completion of certification hours with the local orthopedic sports medicine journal club which included orthos, FM docs specializing in sports medicine and PTs that went over joint exams and how to properly perform and dx MSK complaints. I don't know that I necessarily have a problem with PT's in that I usually order evaluate and treat and if it's required, I give a minimum of 3x weekly x 2 weeks to start with. Having a colleague who's a former PT, the "docs don't know diddly about doing a proper exam/dx/whatever" seems to be ingrained in PTs from day 1 and you seem to have picked up more than your share of that -- good luck to you and I wish you well in your career....Unfortunately, I think @Blue Dog nailed it....
 
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Cool input. I've been a PT for almost 10 years. My bosses/coworkers and I enjoy working with one another and I'd like to think I provide good care (been at the same hospitals for about 5 yrs). Thats 3 years of PT school and about 20k hours of experience as a PT. I didn't get a couple months rotating with a family medicine physician and then think I'm qualified to order "some family medicine" or talk to patients about family medicine. You guys write all kind of nonsense about "PT" but I often just disregard it because that's all it is and it usually doesn't help the patient or PT's doing their job. There's a difference between a hundred observation hours and going thru the schooling and actually doing the job. See if you can work as a PT (if you can "order it" logic says you should be able to do everything I can) then do it about 5 years with full commitment, then you'll have a clue, then you'll be qualified to have input, until then you should probably shut up and do your own job.
 
VA Hopeful Dr said:
Dude is notorious for stirring up trouble with the pain management and PM&R folks
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personally-i-think-uwrfko.jpg
 
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Fiveoboy11 said:
Cool input. I've been a PT for almost 10 years. My bosses/coworkers and I enjoy working with one another and I'd like to think I provide good care (been at the same hospitals for about 5 yrs). Thats 3 years of PT school and about 20k hours of experience as a PT. I didn't get a couple months rotating with a family medicine physician and then think I'm qualified to order "some family medicine" or talk to patients about family medicine. You guys write all kind of nonsense about "PT" but I often just disregard it because that's all it is and it usually doesn't help the patient or PT's doing their job. There's a difference between a hundred observation hours and going thru the schooling and actually doing the job. See if you can work as a PT (if you can "order it" logic says you should be able to do everything I can) then do it about 5 years with full commitment, then you'll have a clue, then you'll be qualified to have input, until then you should probably shut up and do your own job.
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Well, given all that experience, you should understand that when an FM or whatever doc writes a PT "order", it's really an indication/authorization to get my patient over to PT (or have PT come onto the case if hospital/home bound) and do their evaluation/treatment for their area of specialization. I'm personally not telling them what modalities to use or whatever. And this works both ways -- I've had patients come to me after the PT "diagnosed" them with whatever, got them scared and put a treatment plan in their head, that I had to unravel and convince the patient that no, we didn't need a "million dollar workup" for their affliction, we just needed the PT to "shut and do their job" -- same thing happens with pharmacists and now dentists so don't take it personal. Everyone wants to be king **** of turd island in medicine -- if people would just stay in their lanes and cooperate for patient health, it would be a whole lot easier. Never said I could do a PTs job -- investigated it during my engineering to medicine transition and it looked too boring for my tastes, but to each his own....
 
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Mad Jack said:
Wasn't aware FM was allowed to do CC fellowships these days.
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Off topic, came upon your thread from Cabin's locums thread, did you end up pursuing this or did you end up doing full time?

Based on what you had written 3-4 years ago (haha), that's exactly what I want to do, i.e. travel volunteer for 3-4 months at a time. So asking if you've gone through it and help me a bit with it too fresh out of PCSM Fellowship. (looking to do hospitalist work).

((Also, the PT who is saying that we aren't "qualified" or aren't "trained" in ordering PT.. um, actually we are, and me as a provider when I write on the PT script I want an eccentric strengthening program for this guys achilles tendinopathy, than that's exactly what you'll do. I don't want you to do stim, I don't want you to do cryo etc.))
 
septoplasty said:
Off topic, came upon your thread from Cabin's locums thread, did you end up pursuing this or did you end up doing full time?

Based on what you had written 3-4 years ago (haha), that's exactly what I want to do, i.e. travel volunteer for 3-4 months at a time. So asking if you've gone through it and help me a bit with it too fresh out of PCSM Fellowship. (looking to do hospitalist work).

((Also, the PT who is saying that we aren't "qualified" or aren't "trained" in ordering PT.. um, actually we are, and me as a provider when I write on the PT script I want an eccentric strengthening program for this guys achilles tendinopathy, than that's exactly what you'll do. I don't want you to do stim, I don't want you to do cryo etc.))
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Not at that point yet. My life is more stable now, I don't know if I'll be traveling much, given that the best things are at home. Glad to have the opportunity if life changes though, we'll see in a few years.
 
psychMDhopefully said:
So I've been browsing family medicine residency curricula. Usually FM residencies have about 2-3 months of inpatient medicine for 1st of 3rd year, they have 2 or 3 ER months in either year. So, is this training enough to be confident doing hospitalist or ER work? Most FM curricula have residents bounce around to a different rotation every month, I feel like there is no time to solidify any knowledge if you are in a different rotation every month. Also what is the purpose of a one month rotation? What could you become proficent in one month ortho, or derm rotation?
Click to expand...

This thread really went off the rails up there... Anyway, I'm a new FM graduate and I do outpatient, hospitalist, ER, and newborn care including neonatal resuscitation at a smaller 52-bed hospital. It's hard to find jobs that offer a variety of settings like this unless you're willing to live more rural. My residency program trained us well for this; we were unopposed and inpatient heavy in a decently-sized community hospital with a huge OB load. If you're interested in hospitalist/ER shifts then ask questions about what their graduates are doing when interviewing.
 
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