FP in the ER

[FoughtFyr]

You make some good points, but the thing is, I'd be surprised if there were large numbers of students being pressured to choose FM. I've heard many stories of the opposite, where students are actively discouraged from FM, but yours is the only one I've heard of that has the reverse situation.

If you go to the EM pages here it is a common question: "I was thinking about doing EM but I talked to an FP and he/she said I could do FP and then work in an ED and later have an office practice when I want to 'slow down' due to age, family etc.". Happens about once a month. The fact that these medical students seem to all be being lied to in a similar fashion to me makes me believe that this "recruiting" is more common than you think...

- H

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[iatrosB]

If you go to the EM pages here it is a common question: "I was thinking about doing EM but I talked to an FP and he/she said I could do FP and then work in an ED and later have an office practice when I want to 'slow down' due to age, family etc.". Happens about once a month. The fact that these medical students seem to all be being lied to in a similar fashion to me makes me believe that this "recruiting" is more common than you think...

- H

I agree, that has happened to me a few times.

Off topic, however, I've been told a million times by docs in every other specialty to avoid FM.

My solution is to ignore everyone

 

[deleted87716]

If you go to the EM pages here it is a common question: "I was thinking about doing EM but I talked to an FP and he/she said I could do FP and then work in an ED and later have an office practice when I want to 'slow down' due to age, family etc.". Happens about once a month. The fact that these medical students seem to all be being lied to in a similar fashion to me makes me believe that this "recruiting" is more common than you think...

I've never heard that. I certainly haven't told anyone that. If asked, I'd tell them what I've said right here...pick one or the other. They're really worlds apart, IMO.

Family medicine does give you more flexibility in terms of practice options, hours, location, etc. than pretty much any other specialty, however, and there are still job opportunities out there in EM for qualified FM physicians. I don't know how long that will be the case, however.

 

[FoughtFyr]

I've never heard that. I certainly haven't told anyone that. If asked, I'd tell them what I've said right here...pick one or the other. They're really worlds apart, IMO.

Family medicine does give you more flexibility in terms of practice options, hours, location, etc. than pretty much any other specialty, however, and there are still job opportunities out there in EM for qualified FM physicians. I don't know how long that will be the case, however.

I agree with everything above. But just because you are ethical and have a realistic view of your profession, do not assume all of your colleagues do. My personal anecdotal experience and the collective frequent queries in the EM forum suggest that many FPs do not share your views.

- H

 

[finnyel]

you will also learn that not every cardiologist makes $500K/year--some make much less--and not every FP makes $100K--some make much more). quote]

This is infinitely true... I was with my husband as he went through law school. We dreamed big dreams and only now 5 years later are we starting to see anything the least bit big about having a law degree. I fully trust the same lottery is true of medicine.

But my question is this - if FM docs are in short supply, doesn't the economic laws of supply and demand give FP's the ability to demand more money - even more w/ the skills to do both clinic and ER??

One of my hesitations of entering FM is that I'll have worked too hard to not get the respect I'm due. If I want to train for ER the last thing I want is to be told its a waste of my time b/c as a FP I won't be seen as smart enough to handle the trauma. That sounds ridiculous, but if that's how its preceived, that's how its going to be compensated.

 

[deleted77919]

But my question is this - if FM docs are in short supply, doesn't the economic laws of supply and demand give FP's the ability to demand more money - even more w/ the skills to do both clinic and ER??

The issue is you don't set your fees, insurance companies and medicare do. The only real way out is to set up a concierge practice which is not possible for many because either 1) the demand is not that high for their services or 2) individuals have problems with the ethics of only treating the wealthy.

 

[FoughtFyr]

But my question is this - if FM docs are in short supply, doesn't the economic laws of supply and demand give FP's the ability to demand more money - even more w/ the skills to do both clinic and ER??

One of my hesitations of entering FM is that I'll have worked too hard to not get the respect I'm due. If I want to train for ER the last thing I want is to be told its a waste of my time b/c as a FP I won't be seen as smart enough to handle the trauma. That sounds ridiculous, but if that's how its preceived, that's how its going to be compensated.

Because you CAN'T have the skills to do both the clinic and the ED unless you complete an FM residency followed by an EM residency (or vice-versa). It is not a matter of not being "smart enough" to handle the trauma (actually trauma is relatively easy). The question is can you handle 3-4 complicated medical patients, each requiring intensive care and treatment, at once.

Look, EM is like FM in one regard. 90% of what walks in the door anyone could handle. 5% of what walks in the door probably takes a trained and experienced provider to recognize the pathology, but the pathology is not associated with high morbidity and mortality. The remaining 5% takes a trained and experienced provider to recognize and treat, and failure to do so is devastating. Now FM has it's FNPs who do a good job with the basic stuff, but it takes an FP (MD/DO) to handle the complex stuff. It is not a lack of intelligence on the FNPs part, but rather a limited training and experience. Likewise, EM has some FPs hanging around. They do a good job on most stuff, but the 10% of the patients that define the profession - they may well miss...

Let me give you a personal anecdote. I occasionally moonlight in an ED that is run by a group of 5 experienced FPs. An FP is the director of the ED. The volume is roughly 25K a year and they usually have a ~10% admit / transfer rate. Except when I am on. Then the rate is ~25% admit / transfer. So I was called into the directors office. At first, he took a hard line with me, "I'm disappointed that an EM resident has such poor skills etc., etc." Then I asked to review my last 100 patients with him. To my surprise, he agreed. So we sat down with the records on Saturday (I was trying to keep my job...). I had admitted or transferred 23 patients. All but two of them (a 23 year old presumed appy that was later found to be colitis on laproscopy and an 82 year old with a kidney stone with a fever who never got a dirty urine or elevated WBC while inpatient that I admitted for pyelo) where not only justified on review, but were downright necessary. But that meeting scared me! Why? Because as we went over my CP admits, it was clear that while I was using the AHA guidelines on risk stratification for observation units to guide my decisions, the FPs in the ED were going "by feeling and intuition". I had tapped two patients with headaches (again, I was "yelled at" for this, "a CT is sufficient, we don't tap headaches") both were positive - one for SAH the other for markedly elevated CSF protein later determined to be a sentinel incident of her MS. I was concerned that if both of my taps were positive, then I was not tapping enough. He was concerned that I was tapping at all. It is simply a different approach.

FPs, in my experience, working in the ED, treat the patients as though the same patient presented to them in clinic. The differential diagnosis is based first in the most likely disorder with efforts expended to rule that (those) in. This is the traditional medical approach and works well that setting. Unfortunately for those trying to practice both FM and EM, EM uses a completely different approach. In EM the ddx is based on what is most likely to severely injure / kill the patient and efforts are expended to rule that out. If those investigations reveal a non-morbid diagnosis great! Otherwise, with significant pathology reasonably excluded, the patient is sent out to follow up with their PCP (an FP or otherwise) even if no likely diagnosis is made.

Those approaches are very different. They require different mindsets and training to perform. But keep in mind, there is only one standard of care in emergency medicine. If you are sued because your patient has a poor outcome, you will be held to the standards, and approach, of EM. Let's say you look at the patient with the headache, and the negative CT, and convince yourself that a tension headache is far more likely than an SAH and send him/her out and they die, you will lose. You don't get to say "in FM we wouldn't do x,y, or z" because you are practicing EM. It doesn't matter if you are a solo practitioner in an ED with only 2,000 patient visits a year, the standards are the standards. It is that simple.

- H

 

[sophiejane]

One of my hesitations of entering FM is that I'll have worked too hard to not get the respect I'm due. If I want to train for ER the last thing I want is to be told its a waste of my time b/c as a FP I won't be seen as smart enough to handle the trauma. That sounds ridiculous, but if that's how its preceived, that's how its going to be compensated.

Ah, the old respect theme. It's been discussed here ...seems like every time it comes up in this forum, the general consensus is that if you need respect, don't do medicine. The only respect that truly matters is that which your patients bestow on you, and if you deserve it, they will give it (most of them ).

Hoping to get respect from other docs may also be a losing battle, no matter what specialty you choose. Medicine appears to be one giant food chain, with the "bigger" fish constantly feeding on the little ones. General surgeons think OB/Gyns are hacks in the OR. IM thinks FM is full of underachievers. Everyone picks on psych. These are stereotypes, but you get the idea.

Your motivation to choose any field should be primarily, Do you love it? Can you not see yourself happy doing anything else? A lot of people come to that place, but many never feel passionately about one field. Regardless, basing your decision on money and respect is probably going to leave you disappointed, because nobody gets enough respect or money for what they do.

 

[sophiejane]

If you go to the EM pages here it is a common question: "I was thinking about doing EM but I talked to an FP and he/she said I could do FP and then work in an ED and later have an office practice when I want to 'slow down' due to age, family etc.". Happens about once a month. The fact that these medical students seem to all be being lied to in a similar fashion to me makes me believe that this "recruiting" is more common than you think...

- H

I tend to think this kind of recruiting is coming from older docs who have been around since before EM was what it is today. Both are fairly young professions, but we have to remember that for many years, FM WAS the ED. I think FM has slipped a bit more easily into our role, because really, all they did was add two more years of training to the old-time "generalist" who hung out a shingle after one year. EM is still evolving, don't you think? And as the research and body of knowledge grows, I believe these growing pains will cease and comments like that will become as rare as telling someone they can become a general surgeon on the side, after training in OBGyn.

However, that doesn't change the fact that until you guys are really willing to step up and staff these rural hospitals out in BFE (and until they are able to pay you what you expect to be paid, I guess), you can't really complain about the job the FPs are doing out there, because without them, we'd REALLY have problems.

 

[FPforLife]

With the exception of trauma a fully trained FP could do just as good of a job as an EM doc if the FP did a few months at a busy critical care ED. Most evrything else you get in FP residency. MI, Stroke etc. stuff is almost all protocol in the ED anyway. This comes from my experience working in a big time trauma center. In fact many will tell you that the best ED doc is one who did 3 years of Fp then a 1 year fellowship in EM, straight from an attendings mouth. This is not at all to belittle EM docs, just to say that the training in FP gives you the wide range of pt's you will see in the ED and with some extra time in the ED you can be very proficient, except in trauma, if you want trauma do an EM residency. Yes trauma is mostly primary and secondary survey and procedures, but to be comfortable in the high stress atmosphere, you need a fair amount of experience and training.

For me I like EM to0 so I will do urgent care and some lower level ED shifts at least for a little while, good moonlighting money anyway.

 

[Doc Oc]

The Family Medicine program that I will begin in July has a unique call arrangement that allows you to get more experience in the ER. From 5-11pm on your call nights, you serve as one of the ER physicians. If any admissions come in during that time you do it, and afterwards you just do admissions and floor calls, but this system lends loads of extra ER experience to someone who feels called to FM but wants to work in an ER and feel more competent doing so than the average FM grad.

I don't know which other places do this too, but this is in addition to your ER rotation. The program is Southern Illinois University in Quincy, Illinois.

 

[psychbender]

First, I am just an MS2, so feel free to disregard anything I have to say as ignorant drivel. That having been said, as has been stated before in this thread, it's not trauma experience that makes an EP distinct from a FP. Emergency Physicians are given more training with juggling multiple acutely ill patients at the same time than their Family Medicine counterparts, and have more of a background in critical care. Given enough training, yes, an FP can do the same job as an EP in a busy ED with no apparent difference in patient care or safety. I'd say probably two years of ED and critical care time would be sufficient...for the same total duration as a dual-FM/EM residency approved by ABEM or the AOA.

In fact many will tell you that the best ED doc is one who did 3 years of Fp then a 1 year fellowship in EM, straight from an attendings mouth. This is not at all to belittle EM docs, just to say that the training in FP gives you the wide range of pt's you will see in the ED and with some extra time in the ED you can be very proficient, except in trauma, if you want trauma do an EM residency. Yes trauma is mostly primary and secondary survey and procedures, but to be comfortable in the high stress atmosphere, you need a fair amount of experience and training.

I'd like to challenge this statement. Not necessarily that your attending believes it, but that "many" will tell you that. If many agree that an FP with a 1 year fellowship in the ED is supeior to an EP, then why do we have Emergency Medicine as a separate specialty, entirely? Why is it that the nation as a whole moved away from having internists, surgeons, and FPs staff the EDs, to having people who trained specifically for that arena? Does this same attending think that an FP with a 1 year fellowship in inpatient medicine makes a better hospitalist than an IM-boarded physician? Or that an FP with a 1 year fellowship in obstetrics is better than an OB/GYN? These areas used to all be (and in some places still are) handled by FPs, but those days are ending with increasing medical specialization.

Further, that statement is incredibly belittling and insulting. I fail to see how spending 3 years total between clinic, some surgery, some ED, some critical care is superior in an ED to 3 years total spent between the ED, ICU, some surgery, some clinic time. If there is something to that formula that I am just not getting, please, enlighten me.

All this aside, rest assured, FPs will likely continue to staff EDs in rural and suburban areas until such a time as there are enough EM residency-trained physicians to fill those positions. Several of my friends in class want to go into Family Medicine and provide primary care to rural/underserved areas (mission statement of our school), and as such, they also want to practice part-time in the ED. Considering we don't have enough EPs to staff those hospitals, I am all for it. Hopefully, those that want to practice more EM will spend the extra two years to obtain dual board certification, so they can be even more appropriately skilled providers (unsupervised learning curves suck), and not be pushed out of their position when more EPs move to their area many years from now.

 

[FoughtFyr]

With the exception of trauma a fully trained FP could do just as good of a job as an EM doc if the FP did a few months at a busy critical care ED.

Not even CLOSE! EM is an entirely different approach to the patient than FM.

Most evrything else you get in FP residency. MI, Stroke etc. stuff is almost all protocol in the ED anyway.

Actually, trauma is mostly protocol, complicated medical patients require far more thought and clinical acumen.

This comes from my experience working in a big time trauma center.

Very unlikely this experience was at the provider level or you would likely understand the above.

In fact many will tell you that the best ED doc is one who did 3 years of Fp then a 1 year fellowship in EM, straight from an attendings mouth.

Umm, no. Actually the "ED doc" who has done 3 years of FP and a 1 year fellowship in EM is unlikely to be hired now at any tertiary or academic ED (but there may be "leftover" providers who have been grandfathered in). They are also unlikely to get med mal insurance for an EM practice.

This is not at all to belittle EM docs, just to say that the training in FP gives you the wide range of pt's you will see in the ED and with some extra time in the ED you can be very proficient, except in trauma, if you want trauma do an EM residency.

Again, not even close. The basic approach to the patient is so different that there is not an FP graduated in the past 10 years that I would trust to take my boards for me. EM is a unique approach and there is no way to learn it by a "few months in the ED". Do you really think that we try and train off-service residents in our methodolgy? No, we allow them to do what they do, and we (as faculty and senior residents) make certain that all of the needed things are done on the EM side of life...

Yes trauma is mostly primary and secondary survey and procedures, but to be comfortable in the high stress atmosphere, you need a fair amount of experience and training.

Trauma for the EP is easy. It boils down to airway management and fluid resus. I can teach that to a highly motivated high school student. Now trauma for the surgeon, yeah, that's challenging, but I'm sure with two months in the OR and a mail in certificate from Okeefenokee School of Hair Dressing and Surgery the average FP can handle it.

High stress is the STEMI that rolls in while you are trying to get the central line in the septic patient with the SBP of 70 laying next to the undifferentiated obtunded nursing home patient and the hyperkalemic renal failure patient with peaked T waves and no IV access. That was the first hour of my last shift. Show me the FM residency that prepares you for that...

For me I like EM to0 so I will do urgent care and some lower level ED shifts at least for a little while, good moonlighting money anyway.

Until you get sued.

- H

 

[sophiejane]

I agree with what you say, FF.

BUT no one seems to respond to my comments re: EPs being unwilling to staff small rural EDs. It is my impression that this is where FPs (at least the younger ones) are staffing EDs primarily (correct me if I'm wrong). Until EPs step up, this argument is moot, because no matter what you think of them, FPs are forced to cover the ED, even when they'd rather not. In short, if you don't like the way FPs are handling the EDs in underserved areas, why don't you guys haul yourselves out there and do something about it?

PAs and NPs are already filling some of the void. Which would you rather, a midlevel or an FP staffing the ED?

It's fine to have this theoretical argument, but all that really matters is providing the best care to people who need it, no matter where they live.

As long as most of these smart new (and older) EM grads are going to stay in the city and enjoy their "lifestyle" specialty, those remain our options.

 

[psychbender]

I don't think it's necessarily an issue of EPs not "stepping up," but rather an issue of numbers. There aren't enough EPs right now to staff all the EDs. Emergency Medicine is becoming an increasingly popular specialty, and the ED is an increasingly popular place for patients to go. So, hopefully, more EM residencies will open up over the next several years to increase the supply. Many of the EM-hopefuls at my school want to return home to rural areas, rather than practice in the cities; so some are "stepping up," as you put it. However, so long as there are still well-paying jobs in the cities readily available for new grads, I think we'll see the majority stay in urban areas. Thus, FPs will be able to staff rural EDs for the forseeable future.

 

[FPforLife]

High stress is the STEMI that rolls in while you are trying to get the central line in the septic patient with the SBP of 70 laying next to the undifferentiated obtunded nursing home patient and the hyperkalemic renal failure patient with peaked T waves and no IV access. That was the first hour of my last shift. Show me the FM residency that prepares you for that.

AHH ya that is real tough to treat, not. The STEMI- lets see what to do, hmm, OK ASA, beta blocker, nitro, morphine, O2, lovenox, OH ya and call the cardiologist for emergant cath duh, not tough. SBP of 70- fluids and pressors,
hyperkalemic- calcium carbonate, insulin/glucose/ bicarb/ b agonist. Consider kayexalate. I think it's a rediculous statement to say an FP can't multitask and deal with stress, maybe some lame community programs. Try this one on for size- pt crashing in the ICU- with an ammonia of 300 who needs a central line, art line, ng tube, and a blakemore tube. Mom laboring in OB, 3 patients who need to be admitted in the ED, and 7 pt's your covering in house. Happens all the time at unoopsed programs. We multitask brother all the time.
I never said EM wasn't a respectible specialty or that FP's should staff the ED's, just that many are capable. I find in medicine its always turf battles, we are better, so noone else can come in and take our nich. Flame on

 

[deleted6669]

forget the central line if you don't have time for it with a busy dept and lots of crashing pts....ever used these?
access x 2 in less than 1 min.....
http://www.vidacare.com/Products/index_4_29.html

 

[FPforLife]

emedpa- Ive seen these, but never actually sen them used, I think most people feel uncomfortable with it. Good idea though especially with an ammonia of 300- your pretty encephalopathic.

 

[sophiejane]

I think it's a ridiculous statement to say an FP can't multitask and deal with stress, maybe some lame community programs. Try this one on for size- pt crashing in the ICU- with an ammonia of 300 who needs a central line, art line, ng tube, and a blakemore tube. Mom laboring in OB, 3 patients who need to be admitted in the ED, and 7 pt's your covering in house. Happens all the time at unoopsed programs. We multitask brother all the time.

It ain't all sniffles and ingrown toenails, 8-5 clinic, and med refills.

 

[deleted6669]

emedpa- Ive seen these, but never actually sen them used, I think most people feel uncomfortable with it. Good idea though especially with an ammonia of 300- your pretty encephalopathic.

they have these everywhere I work now and as a former medic I feel very comfortable with the concept of using an IO.
I probably could put EJ's or femoral lines in some folks like those described above( haven't done a subclavian since I was a student so wouldn't try) but the IO is much faster and really not any more painful. they are now approved for both tibial and humeral access in kids and adults and other models can be used directly in the sternum( not a big fan of that idea).
the ez io drill costs 500 bucks and the needles are 100 apiece so it's not something we use every day but with a crashing pt with no quick access it is definitely the way to go. I cover a level 4 e.d. on night shift by myself with 1 nurse, 1 xray tech , and 1 er tech so if the nurse and I both can't get access it's IO time.

 

[deleted87716]

FPs will likely continue to staff EDs in rural and suburban areas until such a time as there are enough EM residency-trained physicians to fill those positions...Considering we don't have enough EPs to staff those hospitals, I am all for it.

So am I.

Hopefully, those that want to practice more EM will spend the extra two years to obtain dual board certification, so they can be even more appropriately skilled providers (unsupervised learning curves suck), and not be pushed out of their position when more EPs move to their area many years from now.

That's what the AAFP's position paper on EM is geared towards, at least that's my take on it (there's a similar thread about this going in the EM forum right now.)

 

[DocWagner]

With the exception of trauma a fully trained FP could do just as good of a job as an EM doc if the FP did a few months at a busy critical care ED. Most evrything else you get in FP residency. MI, Stroke etc. stuff is almost all protocol in the ED anyway. This comes from my experience working in a big time trauma center. In fact many will tell you that the best ED doc is one who did 3 years of Fp then a 1 year fellowship in EM, straight from an attendings mouth. This is not at all to belittle EM docs, just to say that the training in FP gives you the wide range of pt's you will see in the ED and with some extra time in the ED you can be very proficient, except in trauma, if you want trauma do an EM residency. Yes trauma is mostly primary and secondary survey and procedures, but to be comfortable in the high stress atmosphere, you need a fair amount of experience and training.

This type of thinking will get a patient hurt, you sued, and the loss of the respect of your colleagues and nursing staff.

 

[FPforLife]

Is there some sort of monopoly on EM knowledge. Are EM docs really that much smarter or have so much more experience than anyone else, I think not!! Avoiding law suit is about being humble and recognizing when you don't know something and need to look it up or get a consult, NOT about I AM AN EM DOC and KNOW ALL. IF you would spend the time looking at a good FP training program you would realize it prepares you well for most, I never said all of what you need as an EM doc. WHat I am saying is that one can acquire that knowledge, FP docs can read

 

[sophiejane]

I'm going to play Kent here and remind everyone to "discuss the topic, not each other."

If we can't have a grown up conversation that doesn't degenerate into a pissing contest, we'll close the thread.

Carry on.

 

[iatrosB]

I'm going to play Kent here and remind everyone to "discuss the topic, not each other."

If we can't have a grown up conversation that doesn't degenerate into a pissing contest, we'll close the thread.

Carry on.

Unfortunately, it seems topics such as these (turf wars) can never be discussed on SDN without pissing.

 

[deleted87716]

Hmm...FM denigrates EM - that equates to a "****ng contest" (which, by the way, is a TOS violation, as that is profanity). EM responds, and FM says "We'll close the thread".

So...which part of Sophiejane's post did you not understand?

 

[FoughtFyr]

Hmm...FM denigrates EM - that equates to a "****ng contest" (which, by the way, is a TOS violation, as that is profanity). EM responds, and FM says "We'll close the thread".

Clean your own house.

As an EM mod, let me be the second to tell you (and everyone else) "play nice". The problem is there have been too many "you" and "I"s in the posts. Discuss FM and EM in general or I agree with Sophie, the thread should be closed.

(Kent - just lending my support as an EP, it is your forum of course)

- H

 

[deleted87716]

Kent - just lending my support as an EP

It's always welcome.

 

[deleted87716]

I am not saying anything about the poster.

Then we don't have a problem.

Carry on.

 

[Apollyon]

So...which part of Sophiejane's post did you not understand?

The word "****" is vulgar, and a black letter violation of the TOS.

 

[deleted87716]

The word "****" is vulgar, and a black letter violation of the TOS.

If you're referring to "pissing contest," I think I'm going to have to defer to the profanity filter on that one. It's not a blocked word.

 

[deleted109597]

Is there some sort of monopoly on EM knowledge. Are EM docs really that much smarter or have so much more experience than anyone else, I think not!! Avoiding law suit is about being humble and recognizing when you don't know something and need to look it up or get a consult, NOT about I AM AN EM DOC and KNOW ALL. IF you would spend the time looking at a good FP training program you would realize it prepares you well for most, I never said all of what you need as an EM doc. WHat I am saying is that one can acquire that knowledge, FP docs can read

I'm not following. Em docs have 3-4 years residency training in their field. FM docs don't have any more than a couple months.
Your statement could be altered towards any other field. Do anesthesia docs have a monopoly on what they do? Surgeons? Anyone else? No, but they have gone through the training that their boards require to work in their fields.
You can't look stuff up every time. If you haven't experienced it during residency, then people will die because you can't perform the right procedure fast enough if you need to look it up. Unfortunately, this is how it happens.
Also, if you have to consult on every patient because you don't know what is required of EM, then your boss will probably not let you work for too much longer. If only because the consultants (whom you have to call at home, not from upstairs) will complain royally about you.

 

[sophiejane]

The problem is there have been too many "you" and "I"s in the posts.

Thanks, FF. This is more specifically what I wanted to say.

 

[DocWagner]

regarding my comment...it is not necessarily knowledge...but reaction...and perception.

Example, anyone can get sued. But I am board certified in EM. If an FP is not board certified in EM or even residency trained in EM...and we BOTH make the SAME mistake, the perception is that the FP SHOULD NOT HAVE BEEN THERE.

It is important to recognize the standard of care in EM is HIGHER than that if FP, as it is the ED. There is no time for "well it is likely gastro". Furthermore, the attorney representing the patient can simply make a case that "if you aren't board certified or even trained in EM, you were out of your league"...regardless if that is true or not. That being said, even hospital admin look toward groups with HIGHER ratios of board certified to not board certified as being MORE favorable. They can use this in advertisements and marketing.
Also, many of you will find out that when applying for privileges, they will ask you if you are board certified in the field you are practicing.
This is the truth of the matter.

 

[Faebinder]

regarding my comment...it is not necessarily knowledge...but reaction...and perception.

Example, anyone can get sued. But I am board certified in EM. If an FP is not board certified in EM or even residency trained in EM...and we BOTH make the SAME mistake, the perception is that the FP SHOULD NOT HAVE BEEN THERE.

It is important to recognize the standard of care in EM is HIGHER than that if FP, as it is the ED. There is no time for "well it is likely gastro". Furthermore, the attorney representing the patient can simply make a case that "if you aren't board certified or even trained in EM, you were out of your league"...regardless if that is true or not. That being said, even hospital admin look toward groups with HIGHER ratios of board certified to not board certified as being MORE favorable. They can use this in advertisements and marketing.
Also, many of you will find out that when applying for privileges, they will ask you if you are board certified in the field you are practicing.
This is the truth of the matter.

While what you are saying is correct, you skipped around the point they all made which is that everyone says "Yes lets make FM get a certificate before they function in the ED full time."

So.. in the eyes of the neutral medical field who only look at death rates and what not. Is the FM residency + 1 year fellowship ED = 3 years EM residency? What if it was TWO years fellowship + FM residency?

Honestly, I dont see where the turf lines don't blur and the argument is starting to become "my residency is greater than yours". Some might counter argue well why didn't you do EM in the first place... to which I counter argue, maybe they decided later they want to do EM.. maybe they want to do half and half sorta like a lot of EM people want to after 20 years in the ED? Or maybe there is just not enough EM residency spots for everyone and that is what we all dance around, despite the fact that there is plenty of need for EM docs out there.

Turf war... nothing new to see here... move on.

 

[DocWagner]

No, this is not a "turf war"

A "turf war" is about "who should be doing skin biopsies...who should be performing colonoscopies...etc etc"

This is about Emergency Medicine being a SPECIALTY. It is about board certification to become the STANDARD for practice in an Emergency Department. This is NOT a turf battle because the fields are different, the training is different, the didactics in residency are different and the residency competitiveness is different. There are CONTINUING certification requirements yearly for EM board certified docs...this is the future, this is what the ABMS and the federal government wants.

Do I respect and appreciate my FP colleagues...well of course. But to label this a "turf battle" is a bit of a simplistic and uneducated view.

 

[deleted87716]

This is NOT a turf battle because the fields are different, the training is different, the didactics in residency are different and the residency competitiveness is different.

How does that not make it a turf battle?

Example: "Who should be reading brain MRIs, radiology or neurology?" As you said, the training is different, the didactics in residency are different and the residency competitiveness is different. Yet...turf battle.

What this is about, simply, is not using ABEM certification as a mandatory criteria for credentialing a physician to work in a hospital emergency department. That's all.

What if hospitals mandated ABIM certification in order to admit patients to the hospital? Don't you imagine that there would be a justifiable objection from hospital-based FPs?

Emergency medicine, like obstetrics and pediatrics, is within the scope of the appropriately-trained family physician. The fact that pediatrics and obstetrics exist as separate specialties, with their own board certifications, is not an issue, nor should it be an issue with emergency medicine.

 

[polygonal]

Emergency medicine, like obstetrics and pediatrics, is within the scope of the appropriately-trained family physician. The fact that pediatrics and obstetrics exist as separate specialties, with their own board certifications, is not an issue, nor should it be an issue with emergency medicine.

What isn't in the scope of FPs then?

You can read films. Does that mean you can/should function like a radiologist? OB/gyn? Should FPs be doing routine C-sections? I could go on and on. The obvious implication is that you can do XYZ specialty as well as someone who is residency trained. That is a non-sequitur.

I have no beef with family medicine. I rather liked it actually. I have a lot of respect for my FP trainers. But you cannot do EM as well as a residency trained doc, radiology as well as a trained radiologist, OB as well as an OB, etc. I don't get why this is even an argument.

You guys are trained to do family medicine and that's what you are good at. If you want to do EM (or OB, or radiology, or rad onc) then the minimum standard is to do a residency. Anything less is below the current standard and in my opinion putting ego over good patient care.

 

[docB]

Try this one on for size- pt crashing in the ICU- with an ammonia of 300 who needs a central line, art line, ng tube, and a blakemore tube.

Who's putting in blakemore tubes anymore?

 

[FPforLife]

Sorry my comments stirred so much anger, I will thus explain. First off I have a ton of respect for my EM colleagues, some of my best friends are or are becoming. It is true that FP's don't get some of the training such as bedside US, chest tubes, trauma, etc. Very true the didactics are different and I think focus alot more in EM on higher acuity stuff(no experience of course). I think the point is though that much of what is seen in the ED is not high acuity of course.
Really the point here isn't if an FP is better in the ED, for sure not to a board certified EM doc, but can they function at a high level in th ED with some additional training? My opinion is they can. I also think that until there are enough ED physisican we will see them doing just that. Even in large metropolitan cities there are too few ED docs. Just saw on the news in my city, which is one of the largest, fastest growing in the U.S.
The original OP wanted to know if he could, I think so but is obviously hospital, acuity level, area dependant. I think the plus one year certification is a good idea for FP's interested in ED work. Whether anyone agrees with that until there are more ED docs, FP's interested in doing some ED work will continue. Oh and yes blakemore tubes do still get put in, saw one put in a couple months ago, of course doesn't happen everyday
Please no flaming just my opinion.

 

[Apollyon]

If you're referring to "pissing contest," I think I'm going to have to defer to the profanity filter on that one. It's not a blocked word.

So you are setting a precedent that, if it's not blocked by the profanity filter, then it is not in violation to use it? You might want to run that by some admin types, as, bar none, the word "piss" is listed as vulgar or obscene by all dictionaries, and there are other words that are likewise vulgar and/or obscene that the filter does not block.

Or else, be ready for everyone to **** all over the forums.

 

[deleted87716]

So you are setting a precedent that, if it's not blocked by the profanity filter, then it is not in violation to use it?

I invite you to review SDN's Terms of Service (TOS), linked here. I'm not making this stuff up.

SDN's moderation policies are not open for debate in this forum, and I would appreciate it if you would just drop it. Thank you.

 

[kungfufishing]

If you want to practice EM, complete an EM residency and get boarded in the specialty. The notion that a physician not trained in the specialty will be "just as good" is wrong. Do you really think that a graduate of an FM program could run a busy ED as well as someone who has trained and studied specifically for that environment throughout residency?

 

[deleted87716]

Do you really think that a graduate of an FM program could run a busy ED as well as someone who has trained and studied specifically for that environment throughout residency?

I don't think anyone is suggesting that FPs should take over the management of emergency departments at Level 1 trauma centers.

There are plenty of people out there who are board-certified in family medicine who have acquired the knowledge and skills to enable them to function competently in the emergency department. The AAFP's position is simply that they should not be barred from being credentialed simply because of their lack of ABEM certification.

I understand what you and others are arguing, but you're ignoring the fact that at the present time, there simply aren't enough board-certified emergency physicians to go around. One day, perhaps market forces will drive all of the non-ABEM certified physicians out, but that day hasn't come...yet.

 

[sophiejane]

I don't think anyone is suggesting that FPs should take over the management of emergency departments at Level 1 trauma centers.

There are plenty of people out there who are board-certified in family medicine who have acquired the knowledge and skills to enable them to function competently in the emergency department. The AAFP's position is simply that they should not be barred from being credentialed simply because of their lack of ABEM certification.

I understand what you and others are arguing, but you're ignoring the fact that at the present time, there simply aren't enough board-certified emergency physicians to go around. One day, perhaps market forces will drive all of the non-ABEM certified physicians out, but that day hasn't come...yet.

Well said. Hopefully this conversation can now continue with this in mind. It's not a turf war, it's about filling a need (especially in rural and/or underserved areas) that ABEM certified physicians are unable or unwilling to fill at this time.

 

[Sinnman]

Well said. Hopefully this conversation can now continue with this in mind. It's not a turf war, it's about filling a need (especially in rural and/or underserved areas) that ABEM certified physicians are unable or unwilling to fill at this time.

Kinda like the NPs and PAs are doing with primary care.

 

[deleted87716]

Kinda like the NPs and PAs are doing with primary care.

Kinda. There are other issues related to independent practice that don't factor into the EM board certification argument, but it's not entirely dissimilar in the sense that people are filling a need. If there were enough primary care doctors to go around we wouldn't need mid-levels doing it, etc.

Of course, that's not the only reason that mid-levels exist. Many of them function in a cooperative arrangement in a variety of non-primary care settings. Just look around any metropolitan ED.

 

[sophiejane]

Kinda like the NPs and PAs are doing with primary care.

Last time I checked, midlevels were staffing EDs as well. Which would you rather, a PA, NP, or a non-ABEM boarded FP?

I know which one I'd pick if I was the patient. And it's not the midlevel.

 

[Apollyon]

Last time I checked, midlevels were staffing EDs as well. Which would you rather, a PA, NP, or a non-ABEM boarded FP?

I know which one I'd pick if I was the patient. And it's not the midlevel.

I've worked with all three, and I've seen excellent clinicians among all three (and, bar none, SCARY NPs, PAs, and FMs - even two FM docs in the ED who are grads of the same program, in the same year - and one is a superstar that thinks like an EM doc and has it down as good as anyone, and the other is a bomb waiting to explode), and it's not nearly as clear an answer for me.

It's confidence and accuracy and acumen - and experience does make up for less schooling, leveling a lot of the field.

What a LOT of people here lack is direct applicability - who else has worked in the non-academic ED with colleagues that are EM-trained and FM-trained? This excludes FM-only EDs (the oft-mentioned "rural"), academic EDs and residents (FM, EM, and others), people that are office-based FM, and most students.

People get hung up on "ABEM certified" - my group is about 1/2 FM, who (mostly) do fast-track, with a few that do the double-covered intermediate ED shifts, and two that are credentialed by the hospital system to work individually in all parts of all EDs we cover. They have gotten there from hours worked in the department - a "practice track" that the hospital recognizes, irrespective of any board certification. Our group has a tertiary-care hospital ED, two suburban EDs, and a standalone ED. Anyone who says that FM cannot get an urban, tertiary-care EM job in this day and age is wrong, because I have objective evidence to the opposite.

However, no one from FM walks in the front door working everywhere, all the time, as I did.

 

[deleted87716]

That was a well-balanced post, Apollyon. I happen to agree with you entirely.

We've all seen some "scary" ER docs, too...board certification is no guarantee of competency.