2+1 Emergency Medicine

[Orchid]

Just wondering if anyone can comment on working emergency medicine from the Family 2 + 1 option?

 

- lifestyle, shift-work, no call ? any comments here

- limitations compared to 5 year program

- competitiveness (once you are in family, how tough is it to do the +1?)

- location (some common areas that you can practice)

- salary, do you bill as a family doc, bill as emerg doc, can you practice only ER without doing any family?

 

any thoughts would be great.

[Satsuma]

- lifestyle, shift-work, no call ? any comments here

 

Yes, if you do emerg you will need to do shifts. But this means no call if you are just going to do straight emerg. If you decide to combine ER with something else, like hospitalist work or obstetrics etc. (because doing the fam +1 does give you alot of flexibility this way) then you might be doing call. But with ER there is no call...just shifts.

 

Some people don't do well with call, some people do...most people just kind of tolerate it it seems! You need to try it out to see if it works for you.

I personally like the flexibility of shiftwork, but others prefer a regular 8-4 type routine. The shift work means that if you are sharing your life with someone who has a regular schedule, you won't be able to see them every evening, weekend etc. so that has to be ok with everyone.

 

Now...I made my decision about liking shift work, after doing rotations with call. And personally, I think shift work is infinitely better than call. BUT, since having rotations with no call for a few weeks and now having just class and stuyding for the LMCC...so on a regular schedule...I can say that having a regular schedule is VERY nice. So liking shiftwork may be relative to what you were doing before!

 

Depending on where you are shifts can be between 8 and 12 hrs. In an academic/urban hospital, you will be busy. I have been in a rural setting though, and while the shifts were longer, they were not as busy, and there was a room for the doc to get a bit of sleep when there weren't any patients to take care of. Generally, 4 shifts a week is full-time. It doesn't sound like alot, and it is manageable, but more than this is hard with adjusting to the changes in shifts. Most staff docs I have talked to seem to average 1 overnight shift a week (though I have seen some do more). I have been told that it is harder to recover once you start doing more than 1 overnight a week.

 

- limitations compared to 5 year program

 

This is tricky to answer and you can spend alot of time trying to sort it out. You have to look at the 2 programs and decide which you would be happier with and try and figure out where you see yourself practicing.

 

The fam +1 gives you flexibility of splitting your type of practice, or going back to only family if the shiftwork gets to you. So there is loss of flexibility with the 5 year. The 5 year opens up opportunities for fellowships...such as critical care. In some bigger centres it is getting a bit harder to get hired as a fam +1, or at least harder to get full-time position. But right now that is a minority of places....though will get harder as the numnber of 5 year graduates increases I suppose.

 

Easier route to research, admin positions etc with the 5 year...though there are fam + 1 that do these things. So, they tell you it is harder, but then you see the fam +1 doing it...and you are left thinking

 

- competitiveness (once you are in family, how tough is it to do the +1?)

 

Getting the +1 is competitive enough. I think you should only do the 2+1 if you enjoy family and would be ok if you didn't get the +1 (or happy doing a +1 in something else). One of the reasons I chose the 5 year is that I can't really see myself doing family, and I didn't want to do a family residency, and I also just wanted to know what I was doing and not have to worry about another match.

 

There are probably match stats on carms for the R-3 match

 

- location (some common areas that you can practice)

They need emerg docs everywhere, so you can pretty much practice anywhere. Harder to get jobs in bigger centres...and harder with the fam +1.

 

 

- salary, do you bill as a family doc, bill as emerg doc, can you practice only ER without doing any family?

 

You can do just ER as a fam +1. I have heard though, that if you do this for an extended period, then the college will frown on you going back to practice family later on. I think there are ways around this but I am not sure as I did not look too much into the family route.

 

The way you bill depends on the centre you are at. Some you get paid by the hour, some you get paid by the hour with a certain bonus that is dependent on how many pts you saw, I think there are likely very few if any places that do just fee for service.

 

 

Hopefully that helps.

Should get to studying for this LMCC now

[fourtytwo]

Dr. Couz chronicled her journey through residency starting in a 5 year Emerge program and then switching to a 2 + 1. Her blog is about 40% fluff, but if you start from the beginning you get a pretty good idea about how to separate the wheat from the chaff. If you have an afternoon to kill, reading through her blog is probably a good idea. She doesn't explicitly name which school's program she attended, but she gives them nicknames and a clever person can figure out what she's talking about.

[ploughboy]

Dr. Couz chronicled her journey through residency starting in a 5 year Emerge program and then switching to a 2 + 1. Her blog is about 40% fluff, but if you start from the beginning you get a pretty good idea about how to separate the wheat from the chaff. If you have an afternoon to kill, reading through her blog is probably a good idea. She doesn't explicitly name which school's program she attended, but she gives them nicknames and a clever person can figure out what she's talking about.

 

Wow! Thanks for the link!

[ploughboy]

Just wondering if anyone can comment on working emergency medicine from the Family 2 + 1 option?

 

- lifestyle, shift-work, no call ? any comments here

- limitations compared to 5 year program

- competitiveness (once you are in family, how tough is it to do the +1?)

- location (some common areas that you can practice)

- salary, do you bill as a family doc, bill as emerg doc, can you practice only ER without doing any family?

 

any thoughts would be great.

 

Hey,

 

Lifestyle: all emergency medicine involves shift-work, since patients are pretty discourteous and often don't get really sick during business hours. On the other hand, emergency physicians don't do call. When you're not working, you're not working. That's a huge plus in my books.

 

Limitations: Two big ones - geography and fellowships. As far as geography goes, if you really want to work in a big teaching hospital in a major urban centre you'd probably be better served by doing the 5-year program. That said, a good emergency physician is a good emergency physician and there are ccfp-em's working in downtown Toronto, Montreal and Vancouver.

 

Fellowships - I came into med school thinking CCFP-EM, and had I not done some ICU electives in 4th year that's the career path I would have pursued. Unfortunately I couldn't easily do a critical care fellowship from a family medicine residency so here I am, a soon-to-be pgy-1 in emergency medicine. Other fellowships that you can really only do through a Royal College residency include pediatric emergency medicine, trauma, tox, pre-hospital care and transport. On the other hand, you can do sports med, general-practice anaesthesia or become a coroner just as easily from CCFP as from FRCPC.

 

Competitiveness: There was an enlightening moment at my Queen's Family Medicine interview. During the morning information session, the program director asked how many people wanted to do a pgy-3 year. About 80% of the room put up their hands. She then said (paraphrased) "Ya, about 20% of you will actually decide to do a pgy-3. Although you might not feel like it right now, by the end of your pgy-2 year you will actually be competent and proficient."

 

Almost everybody who wants a pgy-3 year gets it, although some people who do a pgy-3 do it under the terms of a rosa. There is still such a shortage of emergency docs that you can probably find several really nice communities to do your return-of-service in, and your biggest problem will be picking one. There is also always the option of challenging the ccfp-em exam, although doing that depends on your own personal confidence as well as being able to get 1600 hours of emergency room experience somewhere.

 

Location: already covered above

 

Money: CCFP-EM docs and FRCPC docs are the same in the eyes of both OHIP and HFO. You will bill the same as your colleagues, but will get to do so two years sooner. The nice thing about CCFP-EM is that you have your family medicine ticket to fall back on when you get sick of emergency medicine or tired of shiftwork. I know a bunch of guys who work 12 shifts/month in a big emergency department and who do half a day a week in a family medicine clinic, just to keep their oars in the water on the family medicine side of things. I also know a couple of CCFP-EMs who work full-time in the emergency room *and* run a full family medicine practice. Oddly enough, they're all South African. Anyway, it's their choice even though that's the path to burnout, imho.

 

Conventional wisdom holds that 5-years post-licensure there is no difference in clinical outcomes between CCFP-EM and FRCPC docs. One of these days I'm actually gonna look up the citation for that, but I tend to believe it because I've worked with some truly awesome CCFP-EM docs. If you're keen and switched-on, you will be a good emergency doc no matter which path you choose.

 

Hope that helps. Let me know if you have specific questions.

 

pb

[Satsuma]

Conventional wisdom holds that 5-years post-licensure there is no difference in clinical outcomes between CCFP-EM and FRCPC docs. One of these days I'm actually gonna look up the citation for that, but I tend to believe it because I've worked with some truly awesome CCFP-EM docs. If you're keen and switched-on, you will be a good emergency doc no matter which path you choose.

 

I've always heard 10 years.

Don't know if there is a study that showed something different

 

Ducharme J, Innes G. The FRCPC vs CCFP(EM): Is there a difference 10 years after residency? CAEP Communiqué 1997;Fall:1-4.

 

It is true, if you are a good doc you will be either way...and if you are a crappy one you still will be crappy after the 5 year program.

 

Something interesting I have noticed...among the emerg community there seems to be alot of respect between the 2+1 and 5 years. One of the reasons might be that they work together, and want to maintain good working relationships. But when I rotate through different specialties...many staff have commented that they notice a difference between the 5 year and 2+1, in terms of appropriate referrals and quality of workup before getting the referral. Something interesting to think about.

 

imo Canada needs to get its act together and come up with 1 training program. I don't personally believe you need 5 years to become a good emergency physician. It only takes 4 to be an internist or pediatrician...and it isn't like emerg requires more skill/knowledge to justify an extra year. Maybe I am wrong. But that is how I see it. Maybe they could have a 4 year program and have fellowship options still available from that route. It would be 1 less year for people who just want to do straight emerg and for those that want to do a fellowship, it wouldn't really change anything since most emerg residents manage to get a year of their fellowship in during the 5 years anyway. (so 1 year as part of the 5 year or 1 year after a 4 year program doesn't change anything)

 

Man...I have to stop thinking about this cause 5 years is seeming like such a long time right now!

[ploughboy]

I've heard various numbers, always offered without citation so I appreciate that you gave me the reference. I'll add it to my "to read" pile (which oddly enough, never seems to get any shorter).

 

I agree that five years is probably a little too long to be a straight-up emergency medicine resident, though maybe I'll think differently when I'm a pgy-5! Programs (and maybe even the College) also seem to recognize that. For instance, my program requires me to do a formal subspecialty year sometime around pgy-4-ish and I'm required to use that time to do things other than bread-and-butter emergency medicine.

 

I also think a unified residency would make a whole lot of sense, but am not optimistic. A classmate of mine did her History of Medicine presentation on the history of EM in Canada. What I took from her talk was that any time in the past that the CCFP and RCPSC started discussing a unified EM residency, they wound up fighting. Maybe circumstances, leadership and egos have changed enough now for there to be some sort of unified residency, but I'm not gonna hold my breath.

 

Cheers!

[leviathan]

I think most agree that EM physicians to the south are pretty competent after their 3 year program. As far as I'm aware nobody up here from a 5 year program has ever said they felt more capable?

[coastalslacker]

I think most agree that EM physicians to the south are pretty competent after their 3 year program. As far as I'm aware nobody up here from a 5 year program has ever said they felt more capable?

 

I was talking to an emerg attending (5 year) who had worked in the States about this. He said ER residency down south is a heck of alot harder than in Canada.

[hp18]

Does anyone know Family Physicians doing few Emergency shifts in a hospital each month? I have seen few experienced family physicians doing that in addition to their regular family practice. How are they paid?

[JewelLeigh]

I will be finishing family medicine residency in 3 months and at that time I will have a regular family practice and will also do 3-4 ER shifts per month. I did not do a 2+1. All the ER docs at our hospital, including family docs doing a few shifts like me, get paid hourly. The hourly rate is more during the night and on holidays. We also get a small percentage of the fee-for-service rate.

[Guest tongtongcuty]

I will be finishing family medicine residency in 3 months and at that time I will have a regular family practice and will also do 3-4 ER shifts per month. I did not do a 2+1. All the ER docs at our hospital, including family docs doing a few shifts like me, get paid hourly. The hourly rate is more during the night and on holidays. We also get a small percentage of the fee-for-service rate.

 

What is the rate for ER doc per hour?

 

thanks

[JewelLeigh]

What is the rate for ER doc per hour?

 

thanks

Varies based on the location and the time of day and weekend vs. weekday. It's over $100 per hour for weekdays and goes up from there where I work.

[leviathan]

I will be finishing family medicine residency in 3 months and at that time I will have a regular family practice and will also do 3-4 ER shifts per month. I did not do a 2+1. All the ER docs at our hospital, including family docs doing a few shifts like me, get paid hourly. The hourly rate is more during the night and on holidays. We also get a small percentage of the fee-for-service rate.

I know you can be eligible to write the CCFP-EM exam after a few years of emerg work, but do you think it would be tough to pass without the extra training? If it is doable, maybe it's not worth the cut in salary for a whole extra year if you can achieve the same goal without doing the +1.

[hking03]

I know you can be eligible to write the CCFP-EM exam after a few years of emerg work, but do you think it would be tough to pass without the extra training? If it is doable, maybe it's not worth the cut in salary for a whole extra year if you can achieve the same goal without doing the +1.

 

the eligibillity was mentioned in another thread I was reading (i'd post the link, but i don't feel like looking for it) but I believe it is 1600 hours during the 4 years working in an ER that allows you to challenge the exam... one would think that they offer this challenge after 4 years because this would give you enough experience and exposure to pass the exam. The debate is whether or not this actually prepares you for being in an ER on your own or not.

 

Also, on the note of taking a pay cut during that extra year of training I seem to remember reading that by moonlighting as a family physician, or hospitalist (depending upon the hospital) you can make a considerable amount provided you put the time in.

 

A blog I was reading (dr couz) brought up this same issue. During her 3rd year of residency she decided to work as a hospitalist and was making quite a bit of money. She was also offered 3000.00 per shift working in the ER but opted out for fear of not being fully prepared.

[olecranon]

i was working with a recent ccfpem grad today who said that if i was interested in emerg i should do the 5 year because it would be easier to get into than the ccfpem nowadays. is ccfpem really THAT competitive?!?!?!

[moo]

i was working with a recent ccfpem grad today who said that if i was interested in emerg i should do the 5 year because it would be easier to get into than the ccfpem nowadays. is ccfpem really THAT competitive?!?!?!

 

I think the CCFP-EM is actually more beneficial than doing the 5 year (overkill) residency. But I don't think it's more competitive.

 

I have met so many family docs who started out in emerg, doing CCFP-EM who, by the time they're in their late 30s, early 40s are burned out and decided to switch back to do FM. They all tell me that doing emerg, while balancing family life is difficult, even if you only work 15 shifts a month. This sounds good, but when many of those shifts are evenings and nights, you burn out quite quickly.

 

One of my colleagues did emerg for a few months after her CCFP-EM and decided to just do FM. Lifestyle was too hard on her.

 

Unfortunately, you can't do that with the FRCPC program. Most med students when they're applying don't know how stressful working full time in emerg is.

[bloh]

I think the CCFP-EM is actually more beneficial than doing the 5 year (overkill) residency. But I don't think it's more competitive.

 

I have met so many family docs who started out in emerg, doing CCFP-EM who, by the time they're in their late 30s, early 40s are burned out and decided to switch back to do FM. They all tell me that doing emerg, while balancing family life is difficult, even if you only work 15 shifts a month. This sounds good, but when many of those shifts are evenings and nights, you burn out quite quickly.

 

One of my colleagues did emerg for a few months after her CCFP-EM and decided to just do FM. Lifestyle was too hard on her.

 

Unfortunately, you can't do that with the FRCPC program. Most med students when they're applying don't know how stressful working full time in emerg is.

 

Let's be realistic here; no one will just "switch back to FM" after being outside the FM setting for 10+ years. You lose a lot of your skills after such a long period of time. The only way that you'd be able to do that is if you get an incredibly flexible job that can accommodate your EM schedule with FM days.

[supafield]

Let's be realistic here; no one will just "switch back to FM" after being outside the FM setting for 10+ years. You lose a lot of your skills after such a long period of time. The only way that you'd be able to do that is if you get an incredibly flexible job that can accommodate your EM schedule with FM days.

 

It hasn't been that long that you even needed to do a residency in family medicine to be a family doctor... and with all the problems you see in emerge that should have been seen by a family doctor first, it's not hard to believe that one could jump pretty quickly back into family from emerge.

[moo]

Let's be realistic here; no one will just "switch back to FM" after being outside the FM setting for 10+ years. You lose a lot of your skills after such a long period of time. The only way that you'd be able to do that is if you get an incredibly flexible job that can accommodate your EM schedule with FM days.

 

Well if you do emerg, I'm sure you can make the transition to FM pretty smoothly. I know a few docs who have done that. Heck, I even know a doc who used to do public health and no clinical medicine that made the transition back to being a family doc... he needed to upgrade his skills by being mentored for six months to prove to the College that he is able, but he did it.

[bloh]

It has a lot to do about comfort level. Sure, you can switch but you'd be so rusty and insufficient I wouldn't want you to be my family doctor. That's an opinion I've gotten from a bunch of EM residents I've talked to and it does make sense.

 

A 6 month retraining isn't an easy switch I'd say. That's not that far from just redoing your residency at 50...which in the grand scheme of things isn't so difficult.

[olecranon]

i was talking to the EM doc last night and he said that most emerg physicians still get paid fee for service out there and that when you have admitted patients on the service and not enough beds to see new patients, the earning potential goes right down the drain which is why there are so many vacancies in the lower mainland right now. The ones that pay hourly are highly competitive to get a position at and most do locums for years before getting a spot.

[leviathan]

It has a lot to do about comfort level. Sure, you can switch but you'd be so rusty and insufficient I wouldn't want you to be my family doctor. That's an opinion I've gotten from a bunch of EM residents I've talked to and it does make sense.

The majority of EM is primary care. I can't see it being that difficult for an experienced EP to switch into a clinic where they are probably seeing the exact same stuff minus the acutely ill patients.

[JewelLeigh]

The majority of EM is primary care. I can't see it being that difficult for an experienced EP to switch into a clinic where they are probably seeing the exact same stuff minus the acutely ill patients.

Speaking as a family doctor who also does ER, I have to completely disagree. You're thinking of same-day, walk-in types of issues, which of course is a not insignificant portion of a family doctor's day. However, a huge portion of family medicine is preventative care, psychiatric supportive care and chronic disease care - none or at least very little of this is dealt with by an ER doc on a regular day.

 

Because most/all of these issues are not acute, an ER doc who didn't mind spending a fair amount of time catching him/herself up on these issues could definitely make the switch. I would imagine that such a person would need to spend a lot of time during clinic and in the evening reading. It's not impossible by any means, but the person would definitely need to be committed to the idea if they wanted to be a good family doc.

 

It makes more sense to me that an ER doc (previously trained in fam med that is), who perhaps was sick of shift work, would switch to a walk-in clinic rather than regular family medicine.

[olecranon]

from what i've seen not really. although at one hospital the older docs split their overnight shift into 11pm-3am and have a younger doc start at 3am to finish up until 7 am.