Competitiveness of IM/EM/CCM programs

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Looking to gain a rough understanding of the different "tiers" of competitiveness of the different EM/IM/CCM programs. The prevailing rule of thumb seems to be that a combined degree is at least as competitive as an EM position, although probably moreso.

I'm very, very interested in Maryland's program in particular, but the fact that it's such a small field with so few residency spots (UM has 2 afaik) is concerning. I'm still an M2, so I'm trying to gauge just how competitive of an applicant I need to be in order to have a shot at these programs.

Any input is appreciated.

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Not to entirely hijack your thread--not really, this may (possibly?) help you in a year--but does anyone know of a place to stay for maryland? Was also thinking about doing a rotation there but not sure about the housing situation. Also looked into maryland, seems nice. Just not sure how to stay there.
 
Looking to gain a rough understanding of the different "tiers" of competitiveness of the different EM/IM/CCM programs. The prevailing rule of thumb seems to be that a combined degree is at least as competitive as an EM position, although probably moreso.

I'm very, very interested in Maryland's program in particular, but the fact that it's such a small field with so few residency spots (UM has 2 afaik) is concerning. I'm still an M2, so I'm trying to gauge just how competitive of an applicant I need to be in order to have a shot at these programs.

Any input is appreciated.

Your "rule of thumb" seems appropriate. Not sure what you mean by "tiers of competitiveness"

Most EMIM programs take 2-3 residents per year, I think SUNY downstate is the largest at 4/year.
 
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Anyone know if its getting more or less competitive this coming cycle for a US IMG?
 
My friend when does it ever get easier for an IMG to match into FP or psych let alone a combined EM/IM/CC residency?
 
True but i hear that the combined programs are usually less competitive then EM alone because of the longer time commitment.
 
True but i hear that the combined programs are usually less competitive then EM alone because of the longer time commitment.
While your statement might be true (spoiler: it's not). It has absolutely nothing to do with the RATE of change of competitiveness of a specialty. You asked "is it [EM/IM] getting less competitive for US IMG?" This implies a change in difficulty over a time period for matching into one specialty. Then you made an irrelevant and incorrect point about comparing combined EM/IM/CCM or EM/IM matches to EM.
 
I heard this from friends who went through the match and application cycle. From the responses here I take it that its mostly not true. My mistake.
 
As a current EM/IM resident, here are my thoughts:
1. Tiers - it is difficult to classify such a small specialty into tiers. Currently there are 29 EM/IM residency spots a year, and 4 (soon to be at least 6) programs offer the EM/IM/CC option, which you choose when you go into your 3rd year, so it has no bearing on your initial application, aside from going to a program that offers this. (The 4 that offer are ECU, Maryland, Ford, and LIJ, and the two that will likely very soon offer are Hennepin and SUNY). I interviewed at all 7 of the programs I applied to, and based on my impressions, I felt like Hennepin and Maryland were the best choices for me. But, all programs will offer excellent training, and you will come out as one of the best clinicians in the hospital.

2. Competitiveness - It will be difficult, regardless, to get into an EM/IM residency as an IMG. I would say that, overall they are more competitive than EM, however slightly less competitive than the top EM programs. I know a number of EM/IM residents, and all of them have Step 1 scores over 240. The biggest thing on interviews is to be able to say why you want to do EM/IM, because truthfully there is no clinical reason to do it, aside from your own desire and interests.
 
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Just some questions for the thread.

1) What do most people with EM/IM do after residency?
2) Could I be a part time hospitalist and part time EM doc? Is that a smart path to take?
3) Is EM/IM something people should go into if they are unsure what they want or if they just cannot choose EM over IM or vice versa.

Any EM/IM that could talk about their experience and what they are doing now?
 
1) Historically, most people do EM alone. This is partly because of the history of EMIM, when the programs were plentiful 30 years ago they were intended to help "legitimize" the nascent EM specialty. People going into the EMIM programs mostly wanted to practice EM. Nowadays, most EMIM people are looking for leadership positions, or wanting to do something more than the average clinical EM or IM graduate.

2) Yes, this is a definite career track with EMIM. Most IM residencies now shy away from procedures, hence the EM expertise is critical. Often you can be the hospitalist/proceduralist and are called to do bedside procedures on the IM floors. I have seen ads looking specifically for EMIMs to fill these roles

3) No; as said above EMIM is for people who want to do something extra, not if they are undecided. Use your M4 year as a decision point instead. If you are still undecided, choose a categorical track, then if you find it unfulfilling you can explore a transfer into a combined program. Transfers the other way (EMIM to EM or IM) are problematic as you are off-schedule
 
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Just some questions for the thread.

1) What do most people with EM/IM do after residency?
2) Could I be a part time hospitalist and part time EM doc? Is that a smart path to take?
3) Is EM/IM something people should go into if they are unsure what they want or if they just cannot choose EM over IM or vice versa.

Any EM/IM that could talk about their experience and what they are doing now?


1) It varies, but seems more common that alot of us are doing EM and critical care. Especially those doing the EM/IM/CC combined residency.
2) Not a smart path to take, you make far less per hour doing hospitalist work. Very few people do this.
3)Absolutely not, only do it if you have a real, solid reason for doing so, otherwise it is wasted years and wasted income.
 
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1) It varies, but seems more common that alot of us are doing EM and critical care. Especially those doing the EM/IM/CC combined residency.
2) Not a smart path to take, you make far less per hour doing hospitalist work. Very few people do this.
3)Absolutely not, only do it if you have a real, solid reason for doing so, otherwise it is wasted years and wasted income.

Thanks for the reply.

1) what is the advantage of doing EM/IM/CC over IM then CC fellowship or CC/Pulm. You do 1 less year of training with the former. Is there a pay difference? Is it because EM better prepares you?
2) What about doing EM/IM to allow for flexibility when I'm in my 50s and cannot handle doing the weekend and night shifts in the ED? Not a good reason?
3) So I am interested in both and want to have both backgrounds. I am interested in doing Academics. It seems like EM/IM really allows for people to go into academic medicine, right? I just don't fully appreciate what people mean when they say academic medicine. Does it mean I will have a role as a faculty, teaching, doing research and seeing patients? That's what I hope it means.
 
1) Historically, most people do EM alone. This is partly because of the history of EMIM, when the programs were plentiful 30 years ago they were intended to help "legitimize" the nascent EM specialty. People going into the EMIM programs mostly wanted to practice EM. Nowadays, most EMIM people are looking for leadership positions, or wanting to do something more than the average clinical EM or IM graduate.

2) Yes, this is a definite career track with EMIM. Most IM residencies now shy away from procedures, hence the EM expertise is critical. Often you can be the hospitalist/proceduralist and are called to do bedside procedures on the IM floors. I have seen ads looking specifically for EMIMs to fill these roles


1) What type of leadership positions do you mean? I would not want to do something administrative, but being faculty, teaching, doing research and seeing patients in the ED sounds like a nice end goal.
2) I would not intend just to be a hospitalist. I would want to do both. It seems like sylvanthus thinks that is a bad idea and not worth the salary cut.

Thanks
 
1) what is the advantage of doing EM/IM/CC over IM then CC fellowship or CC/Pulm. You do 1 less year of training with the former. Is there a pay difference? Is it because EM better prepares you?
2) What about doing EM/IM to allow for flexibility when I'm in my 50s and cannot handle doing the weekend and night shifts in the ED? Not a good reason?
3) So I am interested in both and want to have both backgrounds. I am interested in doing Academics. It seems like EM/IM really allows for people to go into academic medicine, right? I just don't fully appreciate what people mean when they say academic medicine. Does it mean I will have a role as a faculty, teaching, doing research and seeing patients? That's what I hope it means.[/QUOTE]

1) Just depends on what you want to do really. Do you like pulm and want to do pulm clinic? Want to work in the ED also? Just do straight ICU? ED prepares you pretty well for a lot of the procedures and resuscitation, so there is that benefit of going the EM route. Also, pulm/crit may pay better, but also may require more hours (covering pulm clinic patients, bronchs, etc)

2) Not a good reason, you will lose alot of your IM knowledge if you just work ED for years and it would be difficult at best to suddenly switch to pure IM/clinic. Better to get a niche like US, wilderness medicine, admin, etc etc etc than do EM/IM with the plans to fall back on IM later.

3) Yes it is perfect for academics, and yes to faculty, teaching, research, seeing patients, being a PD, aPD, chair, department director, etc etc etc. Also you are the perfect person to be the go between with regards to the ED and medicine floors since you have experience with both.
 
1) what is the advantage of doing EM/IM/CC over IM then CC fellowship or CC/Pulm. You do 1 less year of training with the former. Is there a pay difference? Is it because EM better prepares you?
2) What about doing EM/IM to allow for flexibility when I'm in my 50s and cannot handle doing the weekend and night shifts in the ED? Not a good reason?
3) So I am interested in both and want to have both backgrounds. I am interested in doing Academics. It seems like EM/IM really allows for people to go into academic medicine, right? I just don't fully appreciate what people mean when they say academic medicine. Does it mean I will have a role as a faculty, teaching, doing research and seeing patients? That's what I hope it means.

1) Just depends on what you want to do really. Do you like pulm and want to do pulm clinic? Want to work in the ED also? Just do straight ICU? ED prepares you pretty well for a lot of the procedures and resuscitation, so there is that benefit of going the EM route. Also, pulm/crit may pay better, but also may require more hours (covering pulm clinic patients, bronchs, etc)

2) Not a good reason, you will lose alot of your IM knowledge if you just work ED for years and it would be difficult at best to suddenly switch to pure IM/clinic. Better to get a niche like US, wilderness medicine, admin, etc etc etc than do EM/IM with the plans to fall back on IM later.

3) Yes it is perfect for academics, and yes to faculty, teaching, research, seeing patients, being a PD, aPD, chair, department director, etc etc etc. Also you are the perfect person to be the go between with regards to the ED and medicine floors since you have experience with both.[/QUOTE]

Thanks!
 
Just some questions for the thread.

1) What do most people with EM/IM do after residency?
2) Could I be a part time hospitalist and part time EM doc? Is that a smart path to take?
3) Is EM/IM something people should go into if they are unsure what they want or if they just cannot choose EM over IM or vice versa.

Any EM/IM that could talk about their experience and what they are doing now?

A few thoughts:

1) As was mentioned, historically most people did EM with a tendency to end up in an academic setting. The Hospitalist movement was not as prominent back then so from a monetary and scheduling standpoint EM was more desirable. You now have more people opting for fellowship, administrative leadership opportunities, or varied practice patterns integrated into EM (ie. Observation Medicine).

2) Yes, you can do this however as was pointed out again you would have to take a pay cut unless you were smart about it. For example, in a smaller hospital your skill set could be shopped at a premium. A lot of Hospitalists do not like critically ill patients or procedures. My former chief resident is in a medium sized hospital in rural America and gets almost his ED hourly rate as a "Critical Care Hospitalist" in an open ICU model. His partners are happy to just do the lower acuity non-ICU stuff when he's on and he gets to bypass the Grandma has a CURB 65 of 1 but "I am not comfortable discharging" admits. I have another former chief who does 70% EM and 30% Observation Medicine for a private EM group to keep up both of her skills and her salary is almost the same as if she did just EM since a lot of her partners hate covering the Obs unit. You need a niche or you are going to lose money and after 5 years I think that would be unacceptable.

3) Bad idea. You need a plan - whether thats to do Admin, get a letup to break into a competitive academic market, as a precursor to a fellowship. Eventually we all skew more one way vs another (usually EM) and if you don't have your eye on a long game you are going to be very bitter come Year 3 when your co-residents are starting to get jobs and you're only 1/2 way done. Or when you have to present to people you started intern year with or who were your interns/visiting medical students when your started. Either pick one or have a way that you plan to integrate it. When I interview candidates they have to make me believe or I push for a do not rank designation.

Personally, I am doing EM/IM/CC and am building a substantial profile in academics/administration to augment myself clinically. I am going to focus on passing my IM boards and EM written QE exam this summer/fall before I start entertaining full offers but the preliminary scouting I have done indicates substantial interest from private and academic organizations even unsolicited once they hear my background.

As I see it, about the only thing someone with EM/IM/CC can't do is cut them in the OR which in my preliminary job searches has translated into real value for organizations. EM and CC are both red hot specialties in demand right now and there are shortages as well. As one of my mentors says - "Punch as many tickets as you can while you are young to create options later on". Obviously you must eventually say enough is enough. We have an attending who is a bad ass - EM/IM/Cardiology/Advanced Heart Failure but thats 9-10 years of training and far more than I would be willing to do.

Models I am personally aware of:

Program Director of prominent EM programs
Advanced Heart Failure Cardiologist
EM/IM Pulm CCM
Private EM/Obs Medicine
Private EM/Hospitalist Medicine
Proceduralist (walks in drops lines, tubes, intubates, etc for Hospitalist and then walks out)
EM/IM Program Directors - EM and academic hospitalist ward weeks
Deputy Chief of Staff
Academic Chairs

Read this paper for more insight: http://www.ncbi.nlm.nih.gov/pubmed/19673705

I know a new one is being worked on and should be out at some point in the near future.

Lastly, and a major caveat:
We take a substantial financial hit with the prolonged training which unless you have no debt/independently wealthy is a real issue. This much be strategized or you stand to lose in excess of >$400,000 just with two extra years as a resident. Most EM/IM places let you moonlight in the later years. I can tell you that I now make more than quite a few of my academic EM and IM attendings moonlighting as both a ED doc and Hospitalist in community hospitals. If done right you can come out at the end a real boss from a training and still in a financial situation that is not much different than if you graduated in just 3 years.
 
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2) Not a smart path to take, you make far less per hour doing hospitalist work. Very few people do this.

Your compensation will vary greatly. The jobs that I have seen typically are based out of EM, paid as full-time EM, with periodic assignments to internal medicine. Depending on the hours/equivalent time you negotiate, this could be a pretty good deal. Also, salary is just one part of your overall job satisfaction. Agree with examples described by inspirationmd. You would be a unique (and desirable) skill set and don't have to settle for the standard package.

1) What type of leadership positions do you mean? I would not want to do something administrative, but being faculty, teaching, doing research and seeing patients in the ED sounds like a nice end goal.

All of those would be reasonable directions to head in. I would suggest that EMIM means you are trying to become more than just EM teaching faculty, perhaps you want to be program director, clerkship director, master educator in a specific topic, etc. Agree with what sylvanthus said about academic leadership, being the interdepartmental liaison.
 
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I have another former chief who does 70% EM and 30% Observation Medicine for a private EM group to keep up both of her skills and her salary is almost the same as if she did just EM since a lot of her partners hate covering the Obs unit.

Private EM/Obs Medicine
Proceduralist (walks in drops lines, tubes, intubates, etc for Hospitalist and then walks out)
EM/IM Program Directors - EM and academic hospitalist ward weeks


Lastly, and a major caveat:
We take a substantial financial hit with the prolonged training which unless you have no debt/independently wealthy is a real issue. This much be strategized or you stand to lose in excess of >$400,000 just with two extra years as a resident. Most EM/IM places let you moonlight in the later years. I can tell you that I now make more than quite a few of my academic EM and IM attendings moonlighting as both a ED doc and Hospitalist in community hospitals. If done right you can come out at the end a real boss from a training and still in a financial situation that is not much different than if you graduated in just 3 years.

So I guess I am a little uninformed. I am not really familiar with some of the jobs you listed above.

Private EM/Obs- Why would they not get paid the same as ED doc? Don't all ED docs rotate through Obs as part of their job requirement? Also by doing Obs you maintain your IM skills because its basically low level IM patients that aren't acute enough to admit?

Proceduralist is an actual job title? So all you would do is do stuff hospitalists cannot or won't do? Don't they have IR for that? Also are you saying that would be in addition to and ED or IM job?

What do you mean by EM and academic hospitalists ward weeks? Do PDs typically get to see patients as well? I would not want just an administrative job.

Moonlighting just entails taking available shifts in a hospital or EM? How are you balancing that with the residency life? I have a wife and 6 month old. You think that is a possibility? Or would I never get to see them doing that?

Thanks!
 
Your compensation will vary greatly. The jobs that I have seen typically are based out of EM, paid as full-time EM, with periodic assignments to internal medicine. Depending on the hours/equivalent time you negotiate, this could be a pretty good deal. Also, salary is just one part of your overall job satisfaction. Agree with examples described by inspirationmd. You would be a unique (and desirable) skill set and don't have to settle for the standard package.



All of those would be reasonable directions to head in. I would suggest that EMIM means you are trying to become more than just EM teaching faculty, perhaps you want to be program director, clerkship director, master educator in a specific topic, etc. Agree with what sylvanthus said about academic leadership, being the interdepartmental liaison.

So it sounds like you have to sell yourself a certain way and be a good negotiator when it comes time to signing a contract.

You guys are convincing me. Too bad there are only 11 programs available, and some of them my wife would not be happy applying to because of location.
 
Private EM/Obs- Why would they not get paid the same as ED doc? Don't all ED docs rotate through Obs as part of their job requirement? Also by doing Obs you maintain your IM skills because its basically low level IM patients that aren't acute enough to admit?

No, not all Emergency Departments cover the obs unit. Many places have IM-based physicians. "Low-level" is not quite accurate. Mostly the decision to send to obs is because they are sick but don't meet some insurance companies criteria. You provide them high-quality care for the first 24 hours and then they can be safely discharged. Also many patients are admitted for chest pain and need cardiac risk stratification.

Proceduralist is an actual job title? So all you would do is do stuff hospitalists cannot or won't do? Don't they have IR for that? Also are you saying that would be in addition to and ED or IM job?

Yes, it's a job title. You would do bedside procedures all over the hospital. Not a question of who can/will do a procedure. IR is typically less accessible and more expensive, involves radiation (ultrasound can be done at bedside by you). It would be part of your job.

What do you mean by EM and academic hospitalists ward weeks? Do PDs typically get to see patients as well? I would not want just an administrative job.

All PDs see patients. 100% non-patient care, admin jobs for physicians are rare.
 
So I guess I am a little uninformed. I am not really familiar with some of the jobs you listed above.

Private EM/Obs- Why would they not get paid the same as ED doc? Don't all ED docs rotate through Obs as part of their job requirement? Also by doing Obs you maintain your IM skills because its basically low level IM patients that aren't acute enough to admit?

Proceduralist is an actual job title? So all you would do is do stuff hospitalists cannot or won't do? Don't they have IR for that? Also are you saying that would be in addition to and ED or IM job?

What do you mean by EM and academic hospitalists ward weeks? Do PDs typically get to see patients as well? I would not want just an administrative job.

Moonlighting just entails taking available shifts in a hospital or EM? How are you balancing that with the residency life? I have a wife and 6 month old. You think that is a possibility? Or would I never get to see them doing that?

Thanks!

ED/Obs:

There is a hefty salary difference in what EM pays compared to an observation unit. The Relative Value Units (RVUs) generated are just mug different. After 6 hours a lot of ED docs don't really have a huge amount of interest in managing the conditions anyway. Hospitals are interested in obs units as a way to decompress the ED and the hospitalists don't want extra work so this has become a kind of good will/additional revenue stream for ED groups (private and academic). The other partners would rather not have to do it so they give her a increase in hourly rate as its valuable to them to avoid the place. Similar to a shift differential or reduction as a night ED doc. Now in academics the chairman can force you to do it and I'm sure in some other groups as well but that's what I know of her situation.

Obs patients are admitted but as stated its an insurance designation to basically say that the pt is on the hook for the bill primarily. It's an outpatient visit designation of sorts. Beyond your scope at this point but you're basically taking care of an admitted pt

Proceduralist:

As stated yes it is a real position and the general idea is you run a procedure consult service. VIR is at the larger hospitals however the majority of American hospitals are small to medium community hospitals. Plus even at the larger hospitals you will find VIR to be obstructionist at times in the all important effort to get home by 5PM or because the INR is 1.7 won't do the Vascath or paracentesis which increases your length of stay or delays urgent plasmapheresis/dialysis. Nothing like being able to roll up your sleeves and get **** done yourself.

PD work:

Yes you would absolutely see patients as a PD. Hard to assess your residents if they never staff anything with you. A lot of EM/IM academic attendings work mainly EM shifts and then throughout the year have a few 2 week blocks where they are the Internal Medicine attending.

Moonlighting:
We can talk more about this in private if you are interested but suffice it to say yes you can still balance residency, family time and some shifts. I work shifts as a hospitalist and ED doc as they open up and I can put it in my schedule. Early on I did not have a good balance and missed out on family time with my wife and kids that the check at the end of the month didn't make up for at times. Now any shift I take has to have advantages and not be too detrimental to family time (i.e. Really slow so I can study for IM boards in between admits, really high ED rate, precursor to a big purchase/vacation, etc). Wife also has a lot of veto power if she feels I have done to much that month.

In terms of how many shifts a month. Varies by rotation. I do none on inpatient IM months but can squeeze a lot in on other months where he schedule is light and flexible. (i.e. Research months, obs rotation, ID consults, etc).

It's early in the game for you and I applaud that. A lot of medical students have never heard of EM/IM let alone pre-clinical students. Hope to see you on the trail in the future.


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