FM + 1 EM ... where to start

[Vendar]

Hello!!

I am pretty new to the whole CaRMS process and how everything works as a first year. I know some things about it, and I already had a chance to shadow and rule out a few specialties. I find that Family Medicine and Emergency medicine as an option that really appeals to me. Having my own clinical practice for 3-4 days, and then maybe 1 to 2 shifts as EM during the week to see different types of cases is a good fit for me. I am definitely more interested to stay more general than be super focused like dermatology or ophthalmology.

 

My question is if I want to do this 2+1 option, what should I do to have the best chances?

Do I focus most of my electives in FM? Or divide between FM and EM?
Should my research be focused on FM, FM + EM, or only EM?

Any advice is greatly appreciated!

 

Thank you!

[gangliocytoma]

At a talk held by the EM interest group at our school, a couple FM +1 EM docs responded to the question of doing FM and part time EM. They both said that it probably wasn't a good idea because you'd be sacrificing your ability to perform in one or the other. i.e. doing 1 EM shift a week won't give you enough exposure to keep your skills sharp. EM requires you to stay sharp with various skills that you may very rarely use, and working a shift or two a week may mean you may not have the chance to use those skills until you have to, which by that point you may not be as confident/capable and can risk patient safety. Also it's unlikely that you will get your shifts scheduled whenever you please. You may finish a day in the clinic, have to work emerg over night and then do clinic again the next day. 

Likewise, cutting down FM hours to spend more time in emergency will make it harder for your FM patients to access you and will likely need to wait longer to get an appointment with you. This will limit patient accessibility to you.

I do understand that in many small towns there are doctors that do this, but that is likely out of necessity (i.e. lack of true full-time EM docs), but I do think this is something you should consider if you want to go down this route.

[plastics91]

 I have a question in regards to FM + 1 in EM as well. If we choose this route, is there no way for someone doing this to be able to work in a saturated place, for instance like in downtown Toronto? Assuming that the person does relevant research, works hard, etc.

[gangliocytoma]

9 minutes ago, plastics91 said:

 I have a question in regards to FM + 1 in EM as well. If we choose this route, is there no way for someone doing this to be able to work in a saturated place, for instance like in downtown Toronto? Assuming that the person does relevant research, works hard, etc.

As a +1 EM doc? I don't think it would be impossible, but it would be highly unlikely to get hired into an academic centre. Based on rumours I've heard I don't think you would be able to work in a trauma centre as an FM+1EM doctor, but don't quote me on that.

[JohnGrisham]

Another thing to consider is there is some talk about changing how the "+1s" after FM are done. I.e. instead of having fresh grads go straight from residency into a +1, they work for a bit and identify the need for added competency...then go back and receive the training if needed.  The example mentioned, they want to move away from having people specifically going into FM only to go for the +1 EM and not practice any full-scope FM etc.  

Extremely early phases of talk, but just don't go into FM if you only want to practice only EM in a big city and you wont be dissapointed.

[Vendar]

I am not going into FM just for the EM component. I think having a mix of both is something that I find very unique and interesting. 

Given that, should most of my "gunning" be focused on FM and matching in the place I want, or should I make sure that I have EM stuff in there as well? 

Personally, I would want to go back to Vancouver, where I am originally from, but working in academia is not a major priority. 

[JohnGrisham]

7 minutes ago, Vendar said:

I am not going into FM just for the EM component. I think having a mix of both is something that I find very unique and interesting. 

Given that, should most of my "gunning" be focused on FM and matching in the place I want, or should I make sure that I have EM stuff in there as well? 

Personally, I would want to go back to Vancouver, where I am originally from, but working in academia is not a major priority. 

Was not implying that, just throwing an extra line of thought into the mix for other readers  

[Vendar]

4 minutes ago, JohnGrisham said:

Was not implying that, just throwing an extra line of thought into the mix for other readers  

Hehe I know I just wanted to clarify that myself for others!! Sorry I know I am just a first year, but all this has me super anxious and it feels like that I am back in undergrad trying to compete - didn't expect that it would be this hard or complicated!!

[F508]

You don't need to gun for the FM and EM +1 at the undergraduate medical level. When you apply to Carms, you're applying to family medicine. The +1 is a second match, so there is no influence of your first FM match to the second EM +1 match. The only case where you would need to gun is if you want to apply to Dal which has the only integrated FM and EM +1 program (to my knowledge).

Otherwise, I would suggest you do an elective at UBC family med to increase your chance of matching to family in BC.

You could gun for emergency now in case you decide later on that you would rather do the 5 year emergency medicine program which is quiet competitive.

Any emerg related EC at this point would be for yourself. It wouldn't hurt to have done emerg related ECs at the undergraduate level to help boost your application to the +1 program during residency.

 

[F508]

I have a hard time believing that academic ERs are filled with only Royal College R5s given the limited number that they train... I don't doubt if they had the choice to hire a R5 or a +1, they might go for the R5. However, I don't think there's enough R5 ER docs to fill all the emerg shifts of all the academic hospitals in Toronto.. even if there is, you could always work in one of the other hospitals in the GTA area.

[Hanmari]

I recently did an emerg rotation at UHN and I can confirm that there are many 2+1 ER docs there, although I am unsure how many are new hires.

[ralk]

3 hours ago, Vendar said:

Hello!!

I am pretty new to the whole CaRMS process and how everything works as a first year. I know some things about it, and I already had a chance to shadow and rule out a few specialties. I find that Family Medicine and Emergency medicine as an option that really appeals to me. Having my own clinical practice for 3-4 days, and then maybe 1 to 2 shifts as EM during the week to see different types of cases is a good fit for me. I am definitely more interested to stay more general than be super focused like dermatology or ophthalmology.

 

My question is if I want to do this 2+1 option, what should I do to have the best chances?

Do I focus most of my electives in FM? Or divide between FM and EM?
Should my research be focused on FM, FM + EM, or only EM?

Any advice is greatly appreciated!

 

Thank you!

If you want to go for the 2+1 option without any applications to the 5-year EM program, your electives should be typical for that of any other FM applicant. That is, 2-3 FM rotations and then a mix of whatever interests you so long as it has relevance to FM. A few EM electives would probably be recommended, if only to jump-start your abilities for residency and develop contacts as you move towards the +1 applications, but aren't strictly speaking required either.

If you're really looking at a few days of clinical practice plus a few ER shifts each week, I'd probably recommend against doing the +1. Currently, the FM+1 program in ER is more intended for its graduates to work in EM full-time. As the other posters have noted, doing just a bit of one probably leaves you without enough regular experience to be sufficiently competent in both. If that's the practice mix you're looking for, the best option currently would probably be rural practice in places with a small ER department. These are usually staffed by FM docs without a +1 in ER. These ERs function more like walk-in clinics, with fewer patients who tend to be less acute overall. The higher acuity patients still may need to be dealt with, but because resources are limited in these rural ER departments, anything that requires urgent management often has to be shipped out to a larger centre. Overall means fewer skills to maintain (though there are still very valid concerns about whether such patients are receiving a high enough standard of care).

2 hours ago, plastics91 said:

 I have a question in regards to FM + 1 in EM as well. If we choose this route, is there no way for someone doing this to be able to work in a saturated place, for instance like in downtown Toronto? Assuming that the person does relevant research, works hard, etc.

FM +1's work in all sorts of emergency departments, including in saturated areas. Competition for those jobs is fairly steep, and I'm told there are a few hospitals that have practice groups that seem to prefer Royal College applicants (can't say I personally know which ones), but going the FM+1 route doesn't seem to restrict practice location too much, at least for the time being.

[Vendar]

45 minutes ago, ralk said:

If you want to go for the 2+1 option without any applications to the 5-year EM program, your electives should be typical for that of any other FM applicant. That is, 2-3 FM rotations and then a mix of whatever interests you so long as it has relevance to FM. A few EM electives would probably be recommended, if only to jump-start your abilities for residency and develop contacts as you move towards the +1 applications, but aren't strictly speaking required either.

If you're really looking at a few days of clinical practice plus a few ER shifts each week, I'd probably recommend against doing the +1. Currently, the FM+1 program in ER is more intended for its graduates to work in EM full-time. As the other posters have noted, doing just a bit of one probably leaves you without enough regular experience to be sufficiently competent in both. If that's the practice mix you're looking for, the best option currently would probably be rural practice in places with a small ER department. These are usually staffed by FM docs without a +1 in ER. These ERs function more like walk-in clinics, with fewer patients who tend to be less acute overall. The higher acuity patients still may need to be dealt with, but because resources are limited in these rural ER departments, anything that requires urgent management often has to be shipped out to a larger centre. Overall means fewer skills to maintain (though there are still very valid concerns about whether such patients are receiving a high enough standard of care).

FM +1's work in all sorts of emergency departments, including in saturated areas. Competition for those jobs is fairly steep, and I'm told there are a few hospitals that have practice groups that seem to prefer Royal College applicants (can't say I personally know which ones), but going the FM+1 route doesn't seem to restrict practice location too much, at least for the time being.

 

Thank you for your detailed answer. 

You mentioned that the +1s do EM only afterwards. If so, why don't more people do this? A sort of fast track in a way? 
Are there big limitations? 

 

Isn't the whole point of the program to do family med, then emerg sometimes?

[Snowmen]

37 minutes ago, Vendar said:

 

Thank you for your detailed answer. 

You mentioned that the +1s do EM only afterwards. If so, why don't more people do this? A sort of fast track in a way? 
Are there big limitations? 

 

Isn't the whole point of the program to do family med, then emerg sometimes?

I think it simply has to do with the historic fact that ERs have been staffed by FPs in the past and that we're only beginning the transition to a 5-year residency for EM.

[heydere]

I think the advantage of doing a 2+1 is that even if you end up doing EM full-time initially, once the shift work gets to you after a decade or so, you can always transition back to FM full-time. EM has the highest rate of burnout amongst all physicians, so having qualifications in FM is advantageous down the road. 

[ralk]

1 hour ago, Vendar said:

 

Thank you for your detailed answer. 

You mentioned that the +1s do EM only afterwards. If so, why don't more people do this? A sort of fast track in a way? 
Are there big limitations? 

 

Isn't the whole point of the program to do family med, then emerg sometimes?

When EM became a distinct discipline, both the Royal College and the CFPC developed certification pathways. They're considered equivalent, for the most part, because that's how they started. It's a weird historical quirk of our healthcare system. There are pros and cons to doing the 5 year Royal College program vs the 2+1 FM program for EM, which are well-detailed on this site and elsewhere (I won't repeat, please try searching for it, there's plenty already written on this subject), but they essentially lead to the same place. The reason more people don't do 2+1 program is that there are hard caps on the number of +1's available and it is a VERY competitive application. As difficult if not more difficult to get into than the 5-year Royal College residency program, which is itself one of the most competitive residencies to land. And, unlike with a failed application to the 5-year program, if you don't get the +1, that's your only chance (at least as things are currently set up), and you're then stuck as an FP. For those who want to be an FP that's fine, but as I said, most FM+1's in EM do only EM, and so they want to be EM physicians. The 5-year program provides an assurance right from the start that, once all is said and done, you'll be an EM physician.

[heydere]

Whats the typical job expectancy of an ED physician? (i.e. how long before burnout typically occurs)

[JohnGrisham]

1 hour ago, ralk said:

When EM became a distinct discipline, both the Royal College and the CFPC developed certification pathways. They're considered equivalent, for the most part, because that's how they started. It's a weird historical quirk of our healthcare system. There are pros and cons to doing the 5 year Royal College program vs the 2+1 FM program for EM, which are well-detailed on this site and elsewhere (I won't repeat, please try searching for it, there's plenty already written on this subject), but they essentially lead to the same place. The reason more people don't do 2+1 program is that there are hard caps on the number of +1's available and it is a VERY competitive application. As difficult if not more difficult to get into than the 5-year Royal College residency program, which is itself one of the most competitive residencies to land. And, unlike with a failed application to the 5-year program, if you don't get the +1, that's your only chance (at least as things are currently set up), and you're then stuck as an FP. For those who want to be an FP that's fine, but as I said, most FM+1's in EM do only EM, and so they want to be EM physicians. The 5-year program provides an assurance right from the start that, once all is said and done, you'll be an EM physician.

But you can do the challenge pathway as well for the +1. So not all hope is lost.

[F508]

and you can re-apply to the +1 multiple times after you're in practice

[LittleDaisy]

You definitely can. I know a few preceptors who do emergency medicine full-time without the plus 1, in cities 1-2 hours within GTA area, and who subsequently challenge the EM qualification exam after 5 year of working experience. 

Recently CPSO wants the FM grads without +1 in EM who wish to do EM work, to be monitored for 3 months by a back-up EM physician, which could pose challenges to a few rural EM centers who could not afford to have 2 EM physicians at the same time, see recent policy: http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/Expectations-Physicians-Emerg-Med-Rural-Practice.pdf

[A-Stark]

Another fine example of the CPSO (and other colleges) coming up with policies that are either impractical, based on shoddy evidence/rationale, or both. 

[plastics91]

19 hours ago, F508 said:

You don't need to gun for the FM and EM +1 at the undergraduate medical level. When you apply to Carms, you're applying to family medicine. The +1 is a second match, so there is no influence of your first FM match to the second EM +1 match. The only case where you would need to gun is if you want to apply to Dal which has the only integrated FM and EM +1 program (to my knowledge).

Otherwise, I would suggest you do an elective at UBC family med to increase your chance of matching to family in BC.

You could gun for emergency now in case you decide later on that you would rather do the 5 year emergency medicine program which is quiet competitive.

Any emerg related EC at this point would be for yourself. It wouldn't hurt to have done emerg related ECs at the undergraduate level to help boost your application to the +1 program during residency.

 

Thanks everyone for your input, this is tremendously helpful!

It seems from https://www.dfcm.utoronto.ca/enhanced-skills-program that FM + EM application is during CaRMs not a second match? Which tells me there is some gunning to be done during medical school?

I'm debating between specialties. All my life I thought I wanted to do plastics or ENT, but am now coming to terms with what I ultimately value in medicine and outside of medicine, and am shifting towards primary care. I wanted to do FM + EM because there is research I'm hoping to do that lends itself well to essentially expand the scope of practice in each (probably IM to a degree too) using AI. However this means I am interested in working in academic center as both Fam and ER doc which I wasn't sure was really realistic. This post gives me hope that it is possible I will reach out to more people in the field for discussions. Really appreciate any additional comments from the premed101 crew though! Thank you so much!

[F508]

The EM +1 application is done via CaRMS, but it is a second match that occurs during your second year as  FM resident. It's a completely different application called the FM/EM match. Just like how IM has a second match that is processed via CaRMS

[plastics91]

3 hours ago, F508 said:

The EM +1 application is done via CaRMS, but it is a second match that occurs during your second year as  FM resident. It's a completely different application called the FM/EM match. Just like how IM has a second match that is processed via CaRMS

Thanks for replying! What does that mean? Does it mean you apply FM + 1 EM through CaRMS and match but the place you get to ultimately train in is through a separate application (FM/EM match) during residency? If FM + 1 EM is done through CaRMS wouldn't that mean that R3 funding is still attached to the applicant who were successful in FM+1?

[F508]

Hahah I don't really understand what you are describing above.. Let me break it down like this. Applying to FM then to EM +1 is analogous to applying to med school then residency. You apply to a FM program first. You're accepted to school X. Then during your second year of FM residency, you apply to all the schools offering the EM +1 training. The two applications have no impact on each other. Just like how your application to medical school has no impact on your residency application.....

You apply to FM first. Then some FM residents choose to apply to +1 programs. You don't apply to FM + EM during your R-1 Carms application (unless you apply to Dal which has the ONLY integrated program where you don't need to apply for the +1).