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[MD_scientist]

1 hour ago, Lock123 said:

Generally these tend to be low acuity ERs that see “walk-in” type stuff. But people get sick everywhere. People have aortic dissections on vacation in cottage country and drive drunk in rural Ontario leading to a poly trauma.

I’d personally hesitate to work there for 2 reasons:

1. if the goal is to get experience to do full time ER in a larger hospital, I’m not sure the volume of acuity is there to learn those skills. For example, I’m not sure how many LPs or chest tubes or even intubations, one would get to do per year.

2. when stuff does eventually hit the fan, you might be under resourced. It might be difficult to get consults from specialists or to transfer a patient or to get a ct approved 1 hour away. Your nurses might not be very experienced. Perhaps they don’t know how to start a paediatric iv or do a peds in and out catheter. I worked rural very briefly and would not recommend it. It felt like 99% of patients were there for very low acuity type presentations. And I felt I could not deliver high quality care to the other 1% sometimes due to the limited resources I had available to me. I don’t think it strengthened my ER skills at all. 
 

what I found was these ERs were generally staffed by family docs who lived in the area and had true rural practices there (mix of family, Er, ob, hospitalist, etc). That was not for me as I wanted a full time EM practice in a medium to large sized community hospital.

Of course this is all anecdotal 

What if you are a FM resident training in one of these rural sites and would like to apply for the +1 EM or have a full time EM practice after residency in a major hospital ? how would you get enough exposure ? would doing your electives at major hospitals be enough to compensate ?

[JohnGrisham]

2 hours ago, Lock123 said:

Generally these tend to be low acuity ERs that see “walk-in” type stuff. But people get sick everywhere. People have aortic dissections on vacation in cottage country and drive drunk in rural Ontario leading to a poly trauma.

I’d personally hesitate to work there for 2 reasons:

1. if the goal is to get experience to do full time ER in a larger hospital, I’m not sure the volume of acuity is there to learn those skills. For example, I’m not sure how many LPs or chest tubes or even intubations, one would get to do per year.

2. when stuff does eventually hit the fan, you might be under resourced. It might be difficult to get consults from specialists or to transfer a patient or to get a ct approved 1 hour away. Your nurses might not be very experienced. Perhaps they don’t know how to start a paediatric iv or do a peds in and out catheter. I worked rural very briefly and would not recommend it. It felt like 99% of patients were there for very low acuity type presentations. And I felt I could not deliver high quality care to the other 1% sometimes due to the limited resources I had available to me. I don’t think it strengthened my ER skills at all. 
 

what I found was these ERs were generally staffed by family docs who lived in the area and had true rural practices there (mix of family, Er, ob, hospitalist, etc). That was not for me as I wanted a full time EM practice in a medium to large sized community hospital.

Of course this is all anecdotal 

I think a lot of this is very accurate, having been in a few rural ERs.  

[Lock123]

11 minutes ago, MD_scientist said:

What if you are a FM resident training in one of these rural sites and would like to apply for the +1 EM or have a full time EM practice after residency in a major hospital ? how would you get enough exposure ? would doing your electives at major hospitals be enough to compensate ?

Not sure, that’s not something I have any familiarity with. I’m sure people from rural sites match to the em program all the time though. Don’t know if it’s harder or easier or how they’re viewed.

[medigeek]

18 minutes ago, MD_scientist said:

What if you are a FM resident training in one of these rural sites and would like to apply for the +1 EM or have a full time EM practice after residency in a major hospital ? how would you get enough exposure ? would doing your electives at major hospitals be enough to compensate ?

Busy community with few residents is always best. Optimal ratio of pathology and procedures to learners. 

[Edict]

On 2/7/2020 at 10:53 PM, magneto said:

After finishing EM residency, my plan is to initially work mostly in ED in a mid-size city.

From my limited personal experience, most recent CCFP-EM (2+1) grads are choosing to practice in only ED in urban/suburban settings. Very few would go to rural settings.

However, there are many CCFP-EM grads who practice both FM and EM and you can find them in any setting (urban/suburban/rural).

Where would you like to practice? Do you want to do both FM and EM?

In my opinion, I think family medicine residency alone with rotations/electives in EM/ICU/Trauma and hard work is enough to be a competent doctor in a rural setting. I don't think 2+1 is needed (just my opinion).

Again, in my opinion, most CCFP-EM residency programs are very strong and prepare their residents to work in any center in Canada (Tertiary care, Trauma centers, Urban vs Suburban vs Rural etc.). Therefore, most graduates end up working in mid-size (if not large hospitals). However, jobs are not super easy for 2+1 grads at very big academic hospitals but the probability is not zero.

Let me know if I answered your question.

 

Not to offend in anyway, but i'm curious as to your thoughts that a 2+1 is enough to work in tertiary/trauma center. From my residency experience, having done several rotations in ICU/Trauma/EM haven't made me feel confident in working in those settings alone. I certainly can see enhanced learning if this was your area of focus, but my feeling is that it would definitely take a lot of extra self-study/on the job time before I felt like I could do it independently. 

[offmychestplease]

11 minutes ago, Edict said:

Not to offend in anyway, but i'm curious as to your thoughts that a 2+1 is enough to work in tertiary/trauma center. From my residency experience, having done several rotations in ICU/Trauma/EM haven't made me feel confident in working in those settings alone. I certainly can see enhanced learning if this was your area of focus, but my feeling is that it would definitely take a lot of extra self-study/on the job time before I felt like I could do it independently. 

Many 2+1EM's get directly hired on to the biggest ER departments in downtown Toronto upon graduation. 

[Edict]

Just now, offmychestplease said:

Many +1EM's get directly hired on to the biggest ER departments in downtown Toronto upon graduation. 

I know this very well, but my question is more of not whether they are hired, it is, do they truly feel competent in the beginning. I find doing a rotation or two in any specialty often teaches you some stuff but also shows you a whole area that you actually don't know.  

[JohnGrisham]

2 hours ago, Edict said:

I know this very well, but my question is more of not whether they are hired, it is, do they truly feel competent in the beginning. I find doing a rotation or two in any specialty often teaches you some stuff but also shows you a whole area that you actually don't know.  

Definitely valid,  the colleagues I know who went through the +1 year, really grinded extremely hard. They treated it like their version of the royal college year. Because they know they only have 12 months to get as much structured training as they can. Many would pick up extra EM shifts when they could. Most who are gunning for EM +1, also do electives in EM/ICU/CC in R2, and as well have core EM/ICU.  Not to mention, at least 50% of day to day non-trauma EM is squarely in the realm of FM anyways, it's often fine tuning further to the context of EM "flow and risk mitigation".   

They certainly won't feel nearly as comfortable as their 5 year counterparts, and hence why a lot of them are provided with back-up during the first year(s) of practice etc, and emerg docs usually are very collegial regardless. Whenever a trauma or something more complex comes in, most are more than willing to drop their likely benign abdo pain to help out (or at least offer help).  Also a lot of big centres have dedicated trauma teams too, for multi-traumas in particular. 

A typical 5 year EM program will have around 32 blocks of pure EM.    So they by far will have at least 15 blocks of pure EM on top of a 2+1, and will feel much more comfortable.   EM is also a broad field with many different sub-specs these days, and alot of people spend 6-12months of their 5 year residency focusing in on those areas via research or otherwise (areas that wouldn't really be in scope of a generalist EM doc).




 

[Lock123]

I don’t think it’s controversial to say the FRs come out better prepared to work independently followed by the ccfp-Ems and the ccfps who definitely need more hand holding. I can say anecdotally, having worked alongside all 3 at various stages, that advantage tends to disappear and it’s hard/maybe impossible to tell the difference at a certain point in independent practice. In a perfect world, we would train enough FRs and EMs to fill all the EDs across Canada but that’s not realistic. I think more programs like the SEME at u of t need to come along to help provide formal training to ccfps who will staff EDs. CAEP offers some workshops, AIME has a fantastic cadaver airway course, lots of ultrasound courses out there. But there’s no substitute for more time in the ER, in the ICU and in the trauma bay.

[sangria]

@magneto or anyone else:

I am a FM PGY1 who is finding themselves liking emerg much more than expected and I feel a bit lost. The last time I did an emerg rotation was in the very beginning of clerkship. I did not enjoy that experience and thought I was not made for emerg. Always said no thanks to anyone who asked about a 2+1 emerg year. Didn't even want to think about going through CaRMS again.

However, after rotating in emerg as a resident, I find that it's a lot more fun than I remembered. I like the problem solving aspect when tackling undifferentiated problems. I like having a lab/imaging/consultants available on site. I like being on my feet, learning how to cast and repairing lacs...things you don't do in most outpatient FM offices.

Multiple staff have asked me to consider a +1. And surprisingly enough it's been on my mind. Another thing that I did not expect in residency is that I actually enjoy family clinic way less than I thought. I think it has to do with the demands/lack of independence as a resident in my program/site, but it's concerning to me that I would rather to do an emerg shift than clinic, even though I had felt the complete opposite since week 1 of clerkship.

What I DON"T like about emerg: the shift work/working at odd hours sporadically, not having long term relationships with patients, not being able to solve root causes of someone's problems. I am also not sure about the truly acute emerg situations/critical care - is it terrifying because I don't like the acuity or is it because I'm not comfortable/confident about it yet? I can work on one but not the other.

So I know I have got some soul searching to do. Does anyone have any pointers? Everyone I know who wants +1 EM wants to do it BEFORE day 1 of FM residency. How late am I? Are there urgent care centres where they treat things that are less acute but there is lab/imaging support?

[JohnGrisham]

1 minute ago, sangria said:

However, after rotating in emerg as a resident, I find that I'm more confident and so it's a lot more fun than I remembered. I like the problem solving aspect when tackling undifferentiated problems. I like having a lab/imaging/consultants available on site. I like being on my feet, learning how to cast and repairing lacs...things you don't do in most outpatient FM offices.

Caution that alot of that is not true day to day "emerg"

 

2 minutes ago, sangria said:

Multiple staff have asked me to consider a +1. And surprisingly enough it's been on my mind. Another thing that I did not expect in residency is that I actually enjoy family clinic way less than I thought. I think it has to do with the demands/lack of independence as a resident in my program/site, but it's concerning to me that I would rather to do an emerg shift than clinic, even though I had felt the complete opposite since week 1 of clerkship.

 Excellent that you have gotten good feedback - now the question is, what type of emerg centre are you rotating through? Positive feedback is great, but if its in a small rural emerg, or a community emerg that doesn't get many residents is very different than a large emerg that gets lots of breadth of residents.  It is tough that you're specific clinic for FM doesnt get much independence, certainly very variable. I think most of my FM colleagues would agree they enjoyed Emerg shiftwork more than clinic - who wouldnt? Time flies fasters, its more on the go with less busy-work and no paper work to tend to or labs to follow as a resident. It is very idealized. I can almost gaurantee 9/10 FM residents enjoyed their core emerg rotation more than their FM clinics. But majority don't go into EM.

Just throwing some counter points to get you thinking!  Not meant in any way to dissuade. 

 

5 minutes ago, sangria said:

So I know I have got some soul searching to do. Does anyone have any pointers? Everyone I know who wants +1 EM wants to do it BEFORE day 1 of FM residency. How late am I? Are there urgent care centres where they treat things that are less acute but there is lab/imaging support?

Depends on where you live and youre jurisdiciton. Some provinces do have Urgent care centres with onsite labs and some basic imaging - this could be a happy mid ground for you, if you don't like "real" emerg persae and all the less-glamourous work that comes along with it.

EM +1 is extremely competitive in most provinces, and you need to have flexibiltiy with your home program if you haven't already secure electives prior to the Sept 2021 deadline (pretty much you would need to do your elective EM rotations before this to get LORs and that would be Block 1/2 of R2 in most programs/provinces. 

 

[gogogo]

1 hour ago, JohnGrisham said:

Depends on where you live and youre jurisdiciton. Some provinces do have Urgent care centres with onsite labs and some basic imaging - this could be a happy mid ground for you, if you don't like "real" emerg persae and all the less-glamourous work that comes along with it.

What are the downsides to urgent care? Is it something you could do full-time (speaking about the GTA)?

[JohnGrisham]

27 minutes ago, gogogo said:

What are the downsides to urgent care? Is it something you could do full-time (speaking about the GTA)?

It's usually just a bit of a step up from a walk-in-clinic. Not exactly the type of medicine most people who go into emerg want to do. Financially its not bad at all, just in general not everyones interest. But maybe a happy middle ground between FM and hospital based EM.

[Embear]

I'm wondering if any +1s or others can name drop some good family medicine sites/programs that may increase odds of +1. I know things like early elective time is key, but any inside info on sites with EDs that are really receptive to learners wanting +1s, and helping them get there? I'm generally only applying to community or rural based family medicine sites, am I wrong to think attending these sites might provide more opportunities for me to increase my chances of landing a +1?

[emdog]

On 2/6/2021 at 9:24 PM, Embear said:

I'm wondering if any +1s or others can name drop some good family medicine sites/programs that may increase odds of +1. I know things like early elective time is key, but any inside info on sites with EDs that are really receptive to learners wanting +1s, and helping them get there? I'm generally only applying to community or rural based family medicine sites, am I wrong to think attending these sites might provide more opportunities for me to increase my chances of landing a +1?

There may be some minor advantage to being at a specific site. However, it would be different with each school and there are too many family medicine programs. 

I would not concern myself with that. I would focus on family medicine program that would train you well.  And during your training , optimize your chances by doing the usual things (em rotations, electives, courses, reverences etc ). It would be advantageous to go to program that allows large number of electives. 

 

[JohnGrisham]

On 2/6/2021 at 6:24 PM, Embear said:

I'm wondering if any +1s or others can name drop some good family medicine sites/programs that may increase odds of +1. I know things like early elective time is key, but any inside info on sites with EDs that are really receptive to learners wanting +1s, and helping them get there? I'm generally only applying to community or rural based family medicine sites, am I wrong to think attending these sites might provide more opportunities for me to increase my chances of landing a +1?

Early elective time and amount of elective time is the main thing - and N=1 shout out to the Western FM program (colleagues who went through), its an overall slightly less popular FM program due to locations, but has ++ PGY3 spots for EM, so the local home advantage is a bit higher than more popular places like GTA/YVR. 

[jadawo]

Two questions for you all:

1. What is the hourly rate these days for EM work in the most rural emerg department? I’m assuming very rural pays the highest. I found some old posts but they were talking about city rates in like 2012.

2. Do I have this right...if you do 2 years of FM residency, you can easily finds job in rural emergency departments? Then after 4 years of working a certain amount of EM shifts, you can get board certified in emergency medicine? I know the +1 for EM is insanely competitive so I wouldn’t bank on getting one of those spots.

I have more questions but I will try to stop there haha. Please forgive my ignorance, I am American medical student that just discovered the scope of FM in Canada. I am sure you all have plenty to complain about, but if FM in the US was half of the system you all have up north, people would be in literal fist fights to get a residency spot.

 

[bearded frog]

This link explains it pretty well: https://canadiem.org/routes-to-emergency-medicine-practice-following-a-family-medicine-residency/

Here's the official link https://www.cfpc.ca/en/education-professional-development/examinations-and-certification/examination-of-added-competence-in-emergency-medic/eligibility-and-application

I don't know if you can "easily" find a job in a rural emergency department directly out of FM residency, but its possible in theory. I would be interested to see some data to see how many actually take the exam per year through that route. Note that you have to do 400 hours per year, for four continuous years. I don't think the actual number of shifts is unreasonable, its about one 8 hour shift a week.

[jadawo]

10 hours ago, bearded frog said:

This link explains it pretty well: https://canadiem.org/routes-to-emergency-medicine-practice-following-a-family-medicine-residency/

Here's the official link https://www.cfpc.ca/en/education-professional-development/examinations-and-certification/examination-of-added-competence-in-emergency-medic/eligibility-and-application

I don't know if you can "easily" find a job in a rural emergency department directly out of FM residency, but its possible in theory. I would be interested to see some data to see how many actually take the exam per year through that route. Note that you have to do 400 hours per year, for four continuous years. I don't think the actual number of shifts is unreasonable, its about one 8 hour shift a week.

Thanks for your reply! Do you know how much the hourly pay is? Or about how much a usual billing per shift is since I have heard rural is often not hourly but fee for service

[bearded frog]

I do not because

• I'm still in residency
• I'm a pediatrician
• I did my residency and plan to practice at a tertiary academic centre

[JohnGrisham]

7 minutes ago, jadawo said:

Thanks for your reply! Do you know how much the hourly pay is? Or about how much a usual billing per shift is since I have heard rural is often not hourly but fee for service

Varies by province and by region, especially if its hourly or FFS. At a minimum if its a dedicated EM shift for 8hrs you could expect at least 1000$ bare minimum.   

Rural can sometimes pay more, but not always. Semi-rural can pay more but not always. 

The point is, there are way too many variables to answer questions like this unless you narrow down some demographics.  You'll be well compensated regardless of region and rurality. 

[Lock123]

On 2/13/2021 at 12:43 AM, jadawo said:

Two questions for you all:

1. What is the hourly rate these days for EM work in the most rural emerg department? I’m assuming very rural pays the highest. I found some old posts but they were talking about city rates in like 2012.

2. Do I have this right...if you do 2 years of FM residency, you can easily finds job in rural emergency departments? Then after 4 years of working a certain amount of EM shifts, you can get board certified in emergency medicine? I know the +1 for EM is insanely competitive so I wouldn’t bank on getting one of those spots.

I have more questions but I will try to stop there haha. Please forgive my ignorance, I am American medical student that just discovered the scope of FM in Canada. I am sure you all have plenty to complain about, but if FM in the US was half of the system you all have up north, people would be in literal fist fights to get a residency spot.

 

1. Extremely variable. Ive seen as low as 100/hr to as high as $350. Thats before we get into the intricacies of AFA rates vs ffs and how many patients you see per hour and how savvy you are with billing. Would not say "the most rural emerg department" pays the highest. Oftentimes these very rural Eds see a very low volume of patients per 24 hrs. So you are paid to sit and chit chat with your staff members and hang out and see the occasional patient. And then you sleep at night and they only wake you for high acuity patients (rare). The hourly rate for a 24 hr relaxed shift like this would actually be quite low.

2. This is mostly correct. Many rural EDs are extremely desperate for coverage and will hire anyone with FM certification. After 4 years, 400 hours/yr and a written and oral exam, you gain EM certification. This is called the "practice-eligible" route. This does not necessarily mean you are on equal ground with physicians who are RC certified or EM certified by residency training when competing for jobs. Other factors will come into play. Also, they are changing the requirements for which sites can be used for the practice eligible pathway although I am not sure about the details there.  And yes, +1 is very competitive and you should absolutely have a backup plan if ER is your goal. 

[MilwaukeeProtocol]

Can anyone namedrop some rural places that will take FMs to work in the ER without the +1? Are we talking about Timmins or some tiny village on the shores of Hudson's Bay (ie Moose Factory)?

[shikimate]

34 minutes ago, MilwaukeeProtocol said:

Can anyone namedrop some rural places that will take FMs to work in the ER without the +1? Are we talking about Timmins or some tiny village on the shores of Hudson's Bay (ie Moose Factory)?

Looks like you know Ontario, examples would include Kincardine, Listowel, and towns around that size. Slightly larger cities like St Thomas and Woodstock depends, but certainly doable. Bigger cities >100K would be a challenge

Disclaimer: this is only anecdotal evidence, I have no connection to any EM program/department.

[amerus12]

Thank you for all of your responses! I’m a third year medical student and very interested in EM. I’ve been grateful to be able to pick up 1-2 ER shifts per week this last year dispute COVID - my third year is rural. When I’m in the ED, it feels like I’m ‘home’ and a 10 hour shift passes in 5 minutes. I don’t have any experience with tertiary ED and my preceptors are FM ( not plus 1 ) with one 5 year doc.

For the 5-year EM docs here, I was wondering what you picked as your interest area ( e.g. medical education, sports Med, transport, mass casualty, etc. ). is this included in the fourth year or is it a fellowship after? Did you do anything in your clerkship to show your interest?

I’ve read a bit about addictions medicine sub specialty of EM ( but in the states ). Can Canadian 5 year EM docs do this and have an out patient clinic as well as EM? 

Thank you!