FM and PEM

[Doohickey550]

Hi all.

I posted this in the FM forum, but someone suggested that I should post it here.

Is there a possible pathway from FM to pediatric EM (formally or informally)? Say if I’d do lots of pediatric electives during FM residency and complete an EM fellowship, would pediatric emergency departments consider me for a job? Lots of pediatric ERs hire regular pediatricians, so would they be interested in someone with an FM background?

I would have done the usual route via pediatrics, but as of now, I am going to be trying to scramble into peds if I can, but FM as a backup, and I’m wondering if I’ll still be able to pursue PEM to some degree or another.

Edit: I understand that I wouldn’t be eligible to do a PEM fellowship, but I’m just interested in finding about working in that setting.

Thanks for any input.

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[deleted109597]

You cannot do a PEM fellowship, as you haven't done peds or EM. You could do an unaccredited EM fellowship, but I have no way of knowing if this would allow you to work in a pediatric ED or not. I've never seen a familiy doc in any of the peds ERs I've worked at.

 

[GonnaBeADoc2222]

This again...

Sent from my SM-G928V using SDN mobile

 

[InternistDO]

There are no fellowships from FM to EM that grant "real" board certification. There are many rural EDs who will hire you as an FM doc, but they will hire you without a fellowship. Obviously you'll see kids in those jobs, but mostly adults like any ED.

For PEM alone I'd think any hospital willing to hire an FM doc was so desperate that there must be something super wrong with the job or the area.

You could always try to switch into a peds program after intern year. I feel like it would be better to take an extra year of residency rather than trying to wrangle a PEM job from an FM residency. Are you not doing the ACGME match at all?

 

[Lexdiamondz]

Most dedicated peds EDs won't hire an FM trained attending to staff their departments. Some will consider FM for fast-track and most urgent care centres that see kids will still hire you, but for high acuity Peds EDs you generally need to be EM, PEM or gen peds trained.

With that said, IMO PEM fellowship just gives you more exposure to kids, rather than more exposure to sick kids per se. Most peds to PEM fellows don't actually have a great deal of experience with sick kids and critical care procedures, so I'd actually argue that an FM trained doc probably isn't all that bad comparatively.

 

[Tenk]

With that said, IMO PEM fellowship just gives you more exposure to kids, rather than more exposure to sick kids per se. Most peds to PEM fellows don't actually have a great deal of experience with sick kids and critical care procedures, so I'd actually argue that an FM trained doc probably isn't all that bad comparatively.

That’s a really ignorant thing to say.

 

[Lexdiamondz]

That’s a really ignorant thing to say.

I'd have to find it myself, but there's been literature suggesting that the volume of critical patients in a pediatric ER isn't sufficiently high enough for many PEM fellows and attendings to develop and maintain skills in managing critically ill children and performing critical care procedures (intubations, chest tubes, etc). My comment isn't meant to talk down to PEM-trained individuals but there isn't that much sick in PEM compared to EM or PICU


Edit: Linked below
https://www.annemergmed.com/article/S0196-0644(12)00700-7/pdf

 

[deleted480308]

I'd have to find it myself, but there's been literature suggesting that the volume of critical patients in a pediatric ER isn't sufficiently high enough for many PEM fellows and attendings to develop and maintain skills in managing critically ill children and performing critical care procedures (intubations, chest tubes, etc). My comment isn't meant to talk down to PEM-trained individuals but there isn't that much sick in PEM compared to EM or PICU


Edit: Linked below
https://www.annemergmed.com/article/S0196-0644(12)00700-7/pdf

Would you say a peds intensivist would be more appropriate in an ED than a peds ->pem pathway?

 

[Tenk]

I'd have to find it myself, but there's been literature suggesting that the volume of critical patients in a pediatric ER isn't sufficiently high enough for many PEM fellows and attendings to develop and maintain skills in managing critically ill children and performing critical care procedures (intubations, chest tubes, etc). My comment isn't meant to talk down to PEM-trained individuals but there isn't that much sick in PEM compared to EM or PICU


Edit: Linked below
https://www.annemergmed.com/article/S0196-0644(12)00700-7/pdf

I’m aware of that study (and it’s about procedures, not critically ill children) but to say that because of that, FM is similar to peds EM is completely asinine and not true. FM gets almost no experience with sick kids and may not have run a single pediatric code during residency.

If you want to practice EM, do an EM residency. Don’t try to equate some other specialty to ours because they aren’t equal, they are inferior.

 

[deleted109597]

Would you say a peds intensivist would be more appropriate in an ED than a peds ->pem pathway?

They would be way better at the sick kids.
Unfortunately (or fortunately), they would have very little understanding of what to do with the other 95%. So they would likely be just as slow as the pediatricians in the department, but at least they would be able to resuscitate.

 

[Lexdiamondz]

I’m aware of that study (and it’s about procedures, not critically ill children) but to say that because of that, FM is similar to peds EM is completely asinine and not true. FM gets almost no experience with sick kids and may not have run a single pediatric code during residency.

If you want to practice EM, do an EM residency. Don’t try to equate some other specialty to ours because they aren’t equal, they are inferior.

Never said that FM was equivalent to PEM - only that PEM training unfortunately lacks a great deal of acuity. Please don't put words in my mouth, especially since I've been pretty vocal on this forum (and elsewhere) about the merits of EM training for practicing EM.

 

[Tenk]

Most peds to PEM fellows don't actually have a great deal of experience with sick kids and critical care procedures, so I'd actually argue that an FM trained doc probably isn't all that bad comparatively.

Never said that FM was equivalent to PEM - only that PEM training unfortunately lacks a great deal of acuity. Please don't put words in my mouth, especially since I've been pretty vocal on this forum (and elsewhere) about the merits of EM training for practicing EM.

I didn't. You typed that garbage all on your own.

 

[Lexdiamondz]

I didn't. You typed that garbage all on your own.

"Not all that bad" certainly doesn't imply equivalency. Work on those reading comprehension skills, friend.

 

[deleted109597]

Make sure and keep it professional everybody

 

[Tenk]

"Not all that bad" certainly doesn't imply equivalency. Work on those reading comprehension skills, friend.

You’re just grasping for straws because I called you out on your BS. Just admit what you said is not true and move on.

 

[Lexdiamondz]

You’re just grasping for straws because I called you out on your BS. Just admit what you said is not true and move on.

Thanks for your invaluable contribution to the discussion at hand.

 

[Tenk]

Make sure and keep it professional everybody

I’m pretty sure if I went into all the other subspecialty forums and tried to say an EM doctor can do similar care to a board certified fellow in any given specialty, there would be a lot worse words than garbage thrown out there.

 

[Tenk]

Thanks for your invaluable contribution to the discussion at hand.

Thanks for your misguiding advice comparing FM to a board certified specialty of pediatric emergency medicine.

 

[deleted109597]

I’m pretty sure if I went into all the other subspecialty forums and tried to say an EM doctor can do similar care to a board certified fellow in any given specialty, there would be a lot worse words than garbage thrown out there.

And the response from the moderators would be the same. You can say the same thing but nicer and people still understand. I agree that FM and Peds are not the same.

 

[FrkyBgStok]

I recently matched into PEM fellowship from peds and I can say that EM and PEM are very different jobs. I have heard many adult EM docs say that PEM trained people aren’t that proficient in, let’s go with, central lines (any procedure will do). Well compared to many adult docs, neither are the PICU attendings as kids don’t need procedures a nearly as often as adults do. I once heads a PEM doc talk about how all these procedures and diagnoses are rare, but a sick kid is rare in the first place.

I think adults are trained to move meat and have heard that PEM docs aren’t as well trained. I don’t completely disagree but adding in the dynamic of a parent, moving meat isn’t outlet first priority. Like I said before, putting it simply they are just different jobs. So it would be hard to imagine a peds ED accepting a FP physician. Even if you did every elective in peds, you are still at least 2.5 years behind every other peds doc.

 

[GonnaBeADoc2222]

I recently matched into PEM fellowship from peds and I can say that EM and PEM are very different jobs. I have heard many adult EM docs say that PEM trained people aren’t that proficient in, let’s go with, central lines (any procedure will do). Well compared to many adult docs, neither are the PICU attendings as kids don’t need procedures a nearly as often as adults do. I once heads a PEM doc talk about how all these procedures and diagnoses are rare, but a sick kid is rare in the first place.

I think adults are trained to move meat and have heard that PEM docs aren’t as well trained. I don’t completely disagree but adding in the dynamic of a parent, moving meat isn’t outlet first priority. Like I said before, putting it simply they are just different jobs. So it would be hard to imagine a peds ED accepting a FP physician. Even if you did every elective in peds, you are still at least 2.5 years behind every other peds doc.

PEM exists as an academic entity and clinically really isn't necessary. There's no pediatric emergency issue that can't be better handled by an EM trained person +/- consultation with PICU. Your statement that PICU doesn't get adequate exposure to procedures is erroneous. I know multiple PICU docs who are doing central lines, arterial lines, intubations almost every shift.

In residency, it was always the EM residents carrying the bulk of the patients (they even talked to parents!) with even the most senior Peds residents carrying half the load. If I looked at the schedule and saw mostly Pedi residents, I knew it would be a painful shift. The priority in any ED is stabilization and disposition. Reassuring and educating parent should always be part of the process, but the lengthy counseling can be done by their PCP - which is also where probably 95% of peds ED patients should have presented in the first place.

 

[DeadCactus]

It always amazes me how quick some emergency physicians are to disparage their sister specialty and disregard the value of their specialized training. Oh well, now you know how the hospitals and corporations feel about you as they give your jobs away to midlevels...

 

[SpacemanSpifff]

I recently matched into PEM fellowship from peds and I can say that EM and PEM are very different jobs. I have heard many adult EM docs say that PEM trained people aren’t that proficient in, let’s go with, central lines (any procedure will do). Well compared to many adult docs, neither are the PICU attendings as kids don’t need procedures a nearly as often as adults do. I once heads a PEM doc talk about how all these procedures and diagnoses are rare, but a sick kid is rare in the first place.

I think adults are trained to move meat and have heard that PEM docs aren’t as well trained. I don’t completely disagree but adding in the dynamic of a parent, moving meat isn’t outlet first priority. Like I said before, putting it simply they are just different jobs. So it would be hard to imagine a peds ED accepting a FP physician. Even if you did every elective in peds, you are still at least 2.5 years behind every other peds doc.

PEM exists as an academic entity and clinically really isn't necessary. There's no pediatric emergency issue that can't be better handled by an EM trained person +/- consultation with PICU. Your statement that PICU doesn't get adequate exposure to procedures is erroneous. I know multiple PICU docs who are doing central lines, arterial lines, intubations almost every shift.

In residency, it was always the EM residents carrying the bulk of the patients (they even talked to parents!) with even the most senior Peds residents carrying half the load. If I looked at the schedule and saw mostly Pedi residents, I knew it would be a painful shift. The priority in any ED is stabilization and disposition. Reassuring and educating parent should always be part of the process, but the lengthy counseling can be done by their PCP - which is also where probably 95% of peds ED patients should have presented in the first place.

This exchange really just highlights the underlying differences in specialty mentality, which to me is the crux of the matter. Pediatrics training emphasizes education and prevention while our time is spent on learning efficiency and mastering emergent management of life-threatening conditions.

@Doohickey550 why the interest in peds EM? I only spent 6 weeks in a pediatrics clinic during medical school, but my time in the peds ED has been fairly similar. Certainly there are cases of complex kids (we work at a tertiary referral center), and the occasional crumping child, but the vast majority of the clinical care delivered is primary care-esque. I'm not sure working in a pediatric ED offers you a significantly different experience than a primary care clinic.

 

[miacomet]

Most dedicated peds EDs won't hire an FM trained attending to staff their departments. Some will consider FM for fast-track and most urgent care centres that see kids will still hire you, but for high acuity Peds EDs you generally need to be EM, PEM or gen peds trained.

With that said, IMO PEM fellowship just gives you more exposure to kids, rather than more exposure to sick kids per se. Most peds to PEM fellows don't actually have a great deal of experience with sick kids and critical care procedures, so I'd actually argue that an FM trained doc probably isn't all that bad comparatively.

PEM should be a subspecialty of EM only, not peds. It just doesn't work. It's not like a pediatrician can do a two year fellowship and then be a peds orthopedist or urologist.

 

[miacomet]

It always amazes me how quick some emergency physicians are to disparage their sister specialty and disregard the value of their specialized training. Oh well, now you know how the hospitals and corporations feel about you as they give your jobs away to midlevels...

We don't devalue PEM as a specialty. We devalue the lack of competence with acuity and emergencies that is an endemic problem in PEM.

 

[Lexdiamondz]

PEM should be a subspecialty of EM only, not peds. It just doesn't work. It's not like a pediatrician can do a two year fellowship and then be a peds orthopedist or urologist.

One issue is that its really difficult to incentivise an EM physician to nearly double their length of training for a pay cut.

The other issue is that paediatrics (particularly at huge academic, ivory tower type institutions) doesn't really focus on the identification and management of acutely ill patients, something that at least their counterparts in internal medicine do somewhat competently. Rotating w peds residents in the PICU they were all incredibly smart, but also pretty disempowered to take initiative and actually take ownership of sick patient. My institution has a PEM residency and none of the fellows, and only a couple of the attendings are EM trained. The difference in competency with acutely ill patients is pretty palpable.

 

[deleted109597]

My institution has a PEM residency and none of the fellows, and only a couple of the attendings are EM trained. The difference in competency with acutely ill patients is pretty palpable.

What's more annoying is that PEM programs are very cliquish. They either want EM docs, or they want peds docs. Every now and then they'll slum it and take one of the others, but you can pretty easily notice a pattern if you look at prior training of the fellows. Look for this if you ever consider applying for PEM fellowships.

 

[Brigade4Radiant]

Pediatrics in general has a lack of autonomy. You have pediatric urgent care fellowships and hospitalist fellowships. Peds shifts are vital in the ER to differentiate sick kid vs not sick kid.

But pediatric urgent care?? NPs are doing this after they get their online degree.

https://childrensnational.org/resea...d-fellowships/fellowship-programs/urgent-care

Pediatric Hospital Medicine Fellowship | Children's Hospital of Philadelphia

You need three years after a Peds residency to do Peds hospitalist?

 

[miacomet]

Pediatrics in general has a lack of autonomy. You have pediatric urgent care fellowships and hospitalist fellowships. Peds shifts are vital in the ER to differentiate sick kid vs not sick kid.

But pediatric urgent care?? NPs are doing this after they get their online degree.

https://childrensnational.org/resea...d-fellowships/fellowship-programs/urgent-care

Pediatric Hospital Medicine Fellowship | Children's Hospital of Philadelphia

You need three years after a Peds residency to do Peds hospitalist?

I really think Peds is in crisis. Most (not all) residencies give their residents so little autonomy that they can't do anything at graduation aside from well child checks, which can be done just fine by NPs and are done by GPs in pretty much every other country. What are they saying about their trainees that they are so incompetent they have to do fellowships for urgent care and hospital medicine?

 

[FrkyBgStok]

It must be a difference in training and practice. I guess it is hard for me to wrap my brain around because where I’m at, the adult EM docs panic with kids and avoid the very sick kids. The kids are also fully stabilized before they get to the PICU so other than central lines, all procedures are done by the ED attending. Granted, our volume isn’t what others have so we don’t place lines nearly as often as our adult counterparts.

I think you guys are speaking very general and that makes sense because PEM programs do tend to be academic. But again, it is hard for me to wrap my brain around the EM docs being better trained with sick kids because I personally have seen the opposite to be true. But again, I may be in a unique place and in general, it is not like that.

And that is true about hospitalist and urgent care fellowships so maybe coming from peds is the foundation of my argument which is fine.

 

[emergentmd]

Real story. Prob not too relevant but always gives me a chuckle.

PICU attending - Dr emergentsea (working in Adult ER), we have a 3 mo ICU pt that needs a line. The PEM doc can't, PICC team cant, I can't. Can you come over to do a central line?
Me - uhhhhh, No.

 

[Apollyon]

When I was a resident, I was at Duke. In the Peds ED one evening, the pt needs central access. The attending doesn't even consider me (she is peds). She calls the MICU, and the fellow comes down with the smallest triple lumen I've ever seen. Of course, because it is Duke, and it's a fellow, this guy is a colossal condescending prick. Still, he puts in the line, and is continuously passive-aggressive, but gets it done. The peds attending didn't even consider the PICU fellow or attending.

Now, this was 15 years ago. I don't know if things have changed.

 

[LeroyJenkinsMD]

Please keep insecurities to a minimum when family medicine is mentioned. Thanks.

 

[Psai]

Pediatrics in general has a lack of autonomy. You have pediatric urgent care fellowships and hospitalist fellowships. Peds shifts are vital in the ER to differentiate sick kid vs not sick kid.

But pediatric urgent care?? NPs are doing this after they get their online degree.

https://childrensnational.org/resea...d-fellowships/fellowship-programs/urgent-care

Pediatric Hospital Medicine Fellowship | Children's Hospital of Philadelphia

You need three years after a Peds residency to do Peds hospitalist?

Lmao

If you need a fellowship to do urgent care or be a hospitalist, your residency needs to be scrapped

 

[emergentmd]

When I was a resident, I was at Duke. In the Peds ED one evening, the pt needs central access. The attending doesn't even consider me (she is peds). She calls the MICU, and the fellow comes down with the smallest triple lumen I've ever seen. Of course, because it is Duke, and it's a fellow, this guy is a colossal condescending prick. Still, he puts in the line, and is continuously passive-aggressive, but gets it done. The peds attending didn't even consider the PICU fellow or attending.

Now, this was 15 years ago. I don't know if things have changed.

If I was an MICU resident (read adult) and called down to do a central line on Pedi pts in a hospital like Duke with a PICU attending, PEM attending, PME fellow, Anesthsia, Pedi surgery, Pedi surg fellow I would be a colossal Prick too.

Seriously why would this guy even be called until all other first line Peds doc gets a "stab" at it. I know as a fellow has no real say, but I would be like CRAP what are they teaching down there. Atleast give it a try before calling me.

 

[emergentmd]

I trained at one of the biggest county hospitals in the country with an adult hospital next to a Pedi Hospital. Both were referral centers getting everything from everywhere.
During my Adult rotations, I did everything. Saw everything. There was so much meat on the bones that med students got a bunch of scraps.
During my Pedi rotations, it was like vacation. We probably did 6 total months of Pedi rotations from the ICU, Floor, and ER. I got ZERO procedures. There was so little meat on the bones that I don't even remember seeing the Pedi residents or fellows doing procedures. I got so little out of these rotations other than a decent amount of sleep and the food in the Pedi cafeteria was top notch.

Two different worlds. And this is the reason why Pedi EM docs just do not get enough critical care training. There are just very little meat on the bones and this is a reason why PEM docs get paid less than EM docs. There is just very little RVUs on the bones.

 

[miacomet]

I trained at one of the biggest county hospitals in the country with an adult hospital next to a Pedi Hospital. Both were referral centers getting everything from everywhere.
During my Adult rotations, I did everything. Saw everything. There was so much meat on the bones that med students got a bunch of scraps.
During my Pedi rotations, it was like vacation. We probably did 6 total months of Pedi rotations from the ICU, Floor, and ER. I got ZERO procedures. There was so little meat on the bones that I don't even remember seeing the Pedi residents or fellows doing procedures. I got so little out of these rotations other than a decent amount of sleep and the food in the Pedi cafeteria was top notch.

Two different worlds. And this is the reason why Pedi EM docs just do not get enough critical care training. There are just very little meat on the bones and this is a reason why PEM docs get paid less than EM docs. There is just very little RVUs on the bones.

Salaries are catching up. Hospitals want a Peds ER as a marketing technique. Competence is not.

 

[Apollyon]

If I was an MICU resident (read adult) and called down to do a central line on Pedi pts in a hospital like Duke with a PICU attending, PEM attending, PME fellow, Anesthsia, Pedi surgery, Pedi surg fellow I would be a colossal Prick too.

Seriously why would this guy even be called until all other first line Peds doc gets a "stab" at it. I know as a fellow has no real say, but I would be like CRAP what are they teaching down there. Atleast give it a try before calling me.

Duke only had 1 PEM doc. The rest were general peds. This doc, which I remember specifically, was a PICU attending. Yes, weak sauce.

But they were, and, very likely, still are, pricks, because that is who they are. That's Duke in a nutshell.

 

[deleted109597]

the adult EM docs

(working in Adult ER)

There's no such thing as "adult" EM docs or "adult" ERs. We have to see the kids too. It's required to be 20% of our patient volume. We train for emergencies, not age groups.

And yes, there are ER docs that don't like kids. There are ER docs that don't like pregnant women either. And while my anecdote is just as valid as yours @FrkyBgStok, realize that I have seen the pediatric ED throw their hands up for anybody older than 18. Like, won't touch them, whether they have a knife in their gut, chest pain, or passed out volunteering upstairs (I've seen it). That candystriper upstairs? They called 911. Yes, she had a trimal, but she also had hypoglycemia that nobody bothered to evaulate or check before driving her across town.
I've had pediatric radiologists refuse xrays on adults because "they can't read them". I've sat in many, many meetings trying to explain that EMTALA does not have a carve out for pediatric hospitals. They literally tell me that treating and stabilizing is a detriment to the patient and delays transfer.
I don't work at the peds hospital anymore. It's mind numbing.

adult hospital

These actually do exist though. Woe to the poor guy working in the pit that has a 16 year old with appendicitis. The "adult" surgeons at his hospital won't touch him. The peds hospital will inevitably argue about the fact that this kid weighs 200 lbs and therefore is an "adult" to them.
It's maddening. Worse is EMS. Peds hospitals consider anything older than 14 to be an adult in many places.

 

[deuist]

Don't forget the adolescent medicine fellowship. Did the pediatrics residents not learn how to take care of teenagers?

 

[DeadCactus]

Yes, there are hospitalist and urgent care pediatric fellowships. There are also ultrasound fellowships in emergency medicine. These fellowships exist so Dr. Schmuckyschmuck can build some research and administrative experience into their CV and take leadership roles or land competitive jobs. It doesn't mean a pediatric resident doesn't know how to manage an urgent care visit any more than it means an emergency medicine resident doesn't know how to do a FAST exam.

As for the asinine argument that people who have trained for 6 years in an environment and work there full-time are not competent to provide optimal care there, I refer you to literally every single intensivist, trauma surgeon, and subspecialist who uses some microskill their specialty has more experience with and a stream anecdotes to **** on the ineptitude of emergency physicians to do their job. The reality is that PEM as a pediatric subspecialty is housed in tertiary hospitals with subspecialty support down the hall. Care of critically ill children is far more interdisciplinary and the practice of PEM reflects that trend. PEM physicians do the same thing EM physicians due, maintain competency to handle the vast majority of what they deal with and to stabilize critically ill patients long enough for more resources to arrive. A lack of procedural experience does not speak to the lack of competence of a PEM physicians to do their job, it speaks to the different needs of their job.

This thread just makes emergency physicians look insecure and hypocritical and only validates criticisms the field receives from other specialties.

 

[NurWollen]

Yes, there are hospitalist and urgent care pediatric fellowships. There are also ultrasound fellowships in emergency medicine. These fellowships exist so Dr. Schmuckyschmuck can build some research and administrative experience into their CV and take leadership roles or land competitive jobs. It doesn't mean a pediatric resident doesn't know how to manage an urgent care visit any more than it means an emergency medicine resident doesn't know how to do a FAST exam.

As for the asinine argument that people who have trained for 6 years in an environment and work there full-time are not competent to provide optimal care there, I refer you to literally every single intensivist, trauma surgeon, and subspecialist who uses some microskill their specialty has more experience with and a stream anecdotes to **** on the ineptitude of emergency physicians to do their job. The reality is that PEM as a pediatric subspecialty is housed in tertiary hospitals with subspecialty support down the hall. Care of critically ill children is far more interdisciplinary and the practice of PEM reflects that trend. PEM physicians do the same thing EM physicians due, maintain competency to handle the vast majority of what they deal with and to stabilize critically ill patients long enough for more resources to arrive. A lack of procedural experience does not speak to the lack of competence of a PEM physicians to do their job, it speaks to the different needs of their job.

This thread just makes emergency physicians look insecure and hypocritical and only validates criticisms the field receives from other specialties.

 

[deleted109597]

This thread just makes emergency physicians look insecure and hypocritical and only validates criticisms the field receives from other specialties.

Valid points, but there are legitimate concerns about how qualified Peds=>PEM docs are when they finish. When there are peer reviewed journal articles skewering them over "first pass intubation rates" that are flat out lies, then there's an issue. Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. - PubMed - NCBI
Not all PEM docs go to huge academic tertiary sites, and some of the ones they do go to are not very interdisciplinary.

None of us did a peds residency likely, although my wife did, but there are a lot of differences between programs. That being said, we shouldn't comment on them simply because of the fellowships they offer. She got to intubate quite a bit more because they did not have PICU or NICU fellowships at our hospital, the peds resident carried the delivery pager.

With that regard, there are plenty of incomptent EM docs out there as well. All you have to do is go to the facebook page. Or work. We've all seen them. We shouldn't cast everyone in the same mold.

 

[miacomet]

Yes, there are hospitalist and urgent care pediatric fellowships. There are also ultrasound fellowships in emergency medicine. These fellowships exist so Dr. Schmuckyschmuck can build some research and administrative experience into their CV and take leadership roles or land competitive jobs. It doesn't mean a pediatric resident doesn't know how to manage an urgent care visit any more than it means an emergency medicine resident doesn't know how to do a FAST exam.

As for the asinine argument that people who have trained for 6 years in an environment and work there full-time are not competent to provide optimal care there, I refer you to literally every single intensivist, trauma surgeon, and subspecialist who uses some microskill their specialty has more experience with and a stream anecdotes to **** on the ineptitude of emergency physicians to do their job. The reality is that PEM as a pediatric subspecialty is housed in tertiary hospitals with subspecialty support down the hall. Care of critically ill children is far more interdisciplinary and the practice of PEM reflects that trend. PEM physicians do the same thing EM physicians due, maintain competency to handle the vast majority of what they deal with and to stabilize critically ill patients long enough for more resources to arrive. A lack of procedural experience does not speak to the lack of competence of a PEM physicians to do their job, it speaks to the different needs of their job.

This thread just makes emergency physicians look insecure and hypocritical and only validates criticisms the field receives from other specialties.

So how come the PEM folks can't seem to handle trauma or really sick kids? Every place I've worked (and that's a bunch) with PEM they always seem to call the regular EM folks over if kids are really sick. I think that's the issue exactly- PEM folks, or at least many of them, seem incapable of stabilizing or even dealing with critically ill children. And that's a problem.

 

[Doohickey550]

Thanks all for this interesting discussion. As it turns out, I matched into a FM residency in the DO match, so we shall see where exactly it takes me. I was having reservations about peds as it was because I felt it might be more narrow than what I really want to practice. Thanks again for all the valuable input.

 

[jw3600]

Lmao

If you need a fellowship to do urgent care or be a hospitalist, your residency needs to be scrapped

I agree but the thing is they don’t. They are just being thrown under the bus by their speciality. If all of a sudden the internal medicine boards claimed you needed a fellowship to be a hospitalist we all would know it’s bull****. But what would any current resident do about it?

 

[dadaddadaBATMAN]

Yes, there are hospitalist and urgent care pediatric fellowships. There are also ultrasound fellowships in emergency medicine. These fellowships exist so Dr. Schmuckyschmuck can build some research and administrative experience into their CV and take leadership roles or land competitive jobs. It doesn't mean a pediatric resident doesn't know how to manage an urgent care visit any more than it means an emergency medicine resident doesn't know how to do a FAST exam.

As for the asinine argument that people who have trained for 6 years in an environment and work there full-time are not competent to provide optimal care there, I refer you to literally every single intensivist, trauma surgeon, and subspecialist who uses some microskill their specialty has more experience with and a stream anecdotes to **** on the ineptitude of emergency physicians to do their job. The reality is that PEM as a pediatric subspecialty is housed in tertiary hospitals with subspecialty support down the hall. Care of critically ill children is far more interdisciplinary and the practice of PEM reflects that trend. PEM physicians do the same thing EM physicians due, maintain competency to handle the vast majority of what they deal with and to stabilize critically ill patients long enough for more resources to arrive. A lack of procedural experience does not speak to the lack of competence of a PEM physicians to do their job, it speaks to the different needs of their job.

This thread just makes emergency physicians look insecure and hypocritical and only validates criticisms the field receives from other specialties.

One of the things that irritates me is when people stress procedural competence as though that’s what makes you a good em doc or not.

I agree that if you can’t do a chest tube or a central line or intubate then you’re probably incompetent. I disagree with the way people act like that’s the end all be all.

Being competent in procedures is necessary but not sufficient to make you good at em.

Idc that fm residents don’t get a bunch of intubations or a bunch of chest tubes or even a bunch of resuscitations (and at some residencies they actually do). Frankly, critically ill patients are often more straight forward. What I care about is that they don’t spend years in a ed staffing with em docs learning how em docs think and approach an influx of critically ill/about to become ill/subtle presentation/worried well. That’s what makes us different from other specialties. It’s also less tangible.

As for the op, my answer would be that residency is about reliably producing attendings who can safely practice from the beginning to end of their attending careers.

After enough time, most docs could probably become competent in any specialty. But starting out in a setting you didn’t do residency in defeats the purpose of residency, so I would encourage a person interested in Peds em to do Peds or em.

 

[alpinism]

One of the things that irritates me is when people stress procedural competence as though that’s what makes you a good em doc or not.

I agree that if you can’t do a chest tube or a central line or intubate then you’re probably incompetent. I disagree with the way people act like that’s the end all be all.

Being competent in procedures is necessary but not sufficient to make you good at em.

Idc that fm residents don’t get a bunch of intubations or a bunch of chest tubes or even a bunch of resuscitations (and at some residencies they actually do). Frankly, critically ill patients are often more straight forward. What I care about is that they don’t spend years in a ed staffing with em docs learning how em docs think and approach an influx of critically ill/about to become ill/subtle presentation/worried well. That’s what makes us different from other specialties. It’s also less tangible.

As for the op, my answer would be that residency is about reliably producing attendings who can safely practice from the beginning to end of their attending careers.

After enough time, most docs could probably become competent in any specialty. But starting out in a setting you didn’t do residency in defeats the purpose of residency, so I would encourage a person interested in Peds em to do Peds or em.

Agree with the overall message but to play devil's advocate I think we can all agree that EM docs (including PEM docs) should know how to manage status asthmaticus and if not they have no business working in an emergency department. However when it comes to intubating or doing chest tubes for the crashing asthma patient its not a concern for many people and we continue to graduate EM docs who have little to no experience doing the above lifesaving procedures.

 

[turkeyjerky]

Agree with the overall message but to play devil's advocate I think we can all agree that EM docs (including PEM docs) should know how to manage status asthmaticus and if not they have no business working in an emergency department. However when it comes to intubating or doing chest tubes for the crashing asthma patient its not a concern for many people and we continue to graduate EM docs who have little to no experience doing the above lifesaving procedures.

Are we really graduating residents who can't intubate or perform chest tubes? I'd call BS on that. The only EM docs I've seen struggle with the typically resuscitative procedures are older people who lost their skills from working a a sting in UC or never learned them in the first place (not EM trained).

Or are saying we graduate people who are not expert resuscitationists? If so, then, yeah I'd agree with you that there's a curve there.

Regarding the PEM fellows, ostensibly they should be doing gas and PICU rotations to get their procedural numbers up, right? I'm sure some of the incompetence you guys have seen is from skill deterioration

 

[deleted109597]

Are we really graduating residents who can't intubate or perform chest tubes?

EM residencies? None that we know of. I mean, there are probably places where they have too many residents and not enough "sick" people and they're just being used for the labor, but it's probably low.
PEM fellowships? So much that there is literature to that effect. It's even worse in Canada.