IM vs EM?

[A-Stark]

I think one advantage of my current centre is that the four CTU teams are spread across three different - but in close proximity - nursing units. By the end of the first month I didn't necessarily know all the RNs, but I definitely knew the charge nurses after running the list with them everyday. The cardiology ward and CCU were even better in this respect. Then you do call covering all the same floors and work with the same nursing staff again. Each team alternated being on call during the day, so you'd be seeing emerg consults at most twice during the week. And if Meditech isn't exactly state-of-the-art, it remains probably the fastest, simplest EMR around (and we don't dictate discharges).

 

I didn't much like neurology wards much, but I got to know the nurses really well by working with the same nurses all day. And if it served no other purpose, doing a month of emerg ensured I got to know the nursing staff there.

 

Anyway, concerning the IM vs EM thing, another thing to keep in mind is that the procedural experience may be quite different. Some medicine residents (and staff, whether GIM or certain subspecialties) are quite procedure-oriented and will have a lot of experience and comfort with them. Others aren't as aggressive about obtaining the experience. I think this is partly a result of the ever-increasing use of non-medical staff; 30 years ago residents did all the IVs and all the blood draws. Now RTs are around doing blood gases and even art lines. I don't think this is a bad thing, but it means more competition for procedures and even more learners around looking for experience. This somewhat applies in emerg too, but when it comes to quick things like ABGs, it's not a great use of time to page RT, wait for them to page back, and then wait for them to do the gas, considering it takes all of about 30 seconds from setup to completion.

[ploughboy]

We have security guys which can be very key in the ED. They literally saved my butt a few times.

 

One of my favourite memories of residency is discharging this drunken idjit from the ER. He had nothing wrong with him other than a high blood alcohol level and a personality disorder, but he had started to become physically aggressive toward the nurses and other patients so it was time for him to leave.

 

So I told the security guards that he was discharged. One of them picked him up like a sack of potatoes, walked out through the main waiting room with him over his shoulder and deposited him gently on the curb. It was hard not to laugh, and the shocked expressions on the faces of the people in the waiting room were priceless.

 

Dunno what this has to do with IM vs EM other than it was a funny story...

[ploughboy]

Sounds like your experience is/was better than mine. Maybe part of it is being an on-service senior vs an off-service junior, too.

 

Actually, that's a good point for the original poster -- when you're doing your clerkship rotations whether it be in medicine, the ER, surgery or somewhere else, watch what your staff docs are doing with their time (or more importantly, what they're not stuck doing). Imagine yourself in their position in 5-10 years and think about how you'd like it. The life of a staffman is quite different from that of a clerk or a junior resident.

 

Re: procedures. I think that as a group ER residents in general are more keen on doing procedures than medicine residents, but there is much more variability among medicine residents. The folks who want ICU or cardiology are going to be all over lines and tubes, while the person who like, just wants to be, like, an office-based endocrinologist in, like, Oakville is probably going to hold the laryngoscope in the wrong hand.

 

Unfortunately, I think some ER staff in academic centres rely too much on having subspecialty backup and defer too many procedures and too much management because of that. But you didn't hear that from me...

 

 

I think one advantage of my current centre is that the four CTU teams are spread across three different - but in close proximity - nursing units. By the end of the first month I didn't necessarily know all the RNs, but I definitely knew the charge nurses after running the list with them everyday. The cardiology ward and CCU were even better in this respect. Then you do call covering all the same floors and work with the same nursing staff again. Each team alternated being on call during the day, so you'd be seeing emerg consults at most twice during the week. And if Meditech isn't exactly state-of-the-art, it remains probably the fastest, simplest EMR around (and we don't dictate discharges).

 

I didn't much like neurology wards much, but I got to know the nurses really well by working with the same nurses all day. And if it served no other purpose, doing a month of emerg ensured I got to know the nursing staff there.

 

Anyway, concerning the IM vs EM thing, another thing to keep in mind is that the procedural experience may be quite different. Some medicine residents (and staff, whether GIM or certain subspecialties) are quite procedure-oriented and will have a lot of experience and comfort with them. Others aren't as aggressive about obtaining the experience. I think this is partly a result of the ever-increasing use of non-medical staff; 30 years ago residents did all the IVs and all the blood draws. Now RTs are around doing blood gases and even art lines. I don't think this is a bad thing, but it means more competition for procedures and even more learners around looking for experience. This somewhat applies in emerg too, but when it comes to quick things like ABGs, it's not a great use of time to page RT, wait for them to page back, and then wait for them to do the gas, considering it takes all of about 30 seconds from setup to completion.

[Consult]

Can people comment on whether they see a difference between a physician that did a 5 year FRCPC residency vs the 3 year CCFP-EM (Consulting interactions or EM colleagues)?

[The Journey Man]

Can people comment on whether they see a difference between a physician that did a 5 year FRCPC residency vs the 3 year CCFP-EM (Consulting interactions or EM colleagues)?

 

On average, without a doubt I found a difference working with them and receiving consults. Its to be expected.

 

The 5 year docs are much better at handling acuity, teaching students/residents, practicing and teaching evidence based medicine. They on average work their patients up better and more appropriately before referral.

 

The 5 year guys deep down think they are superior the CCFP grads, although everyone is friendly in person. You can't blame them though because its on average true.

 

Now before we hear about anecdotes about the contrary, i stress average. There are stellar CCFP docs who get better every day with reading and experience and are similar to the FRCPC grads. Having said that, i find they are the exception. Conversely there are FRCPC grads who don't care, dont try to get better, punch in and punch out.

 

Its about the mentality as well. The students who get into FRCPC programs tend to be more hardcore so its no surprise that they are real good after 5 years of dedicated training towards Emerg.

 

I have no stake in this as I am in a different field but this is based of my experiences in Emerg and being consulted by them.

[Lactic Folly]

In our program, I don't think we really take note of which consulting ER docs are 5- vs 3- year graduates (unless something happens to make it a question of interest). The main variables surrounding an interaction seem to be 1) individual factors (personality, dedication, judgment, etc.) and 2) amount of experience (of course, the new 3-year grads have the least).

[BoyInTheBubble]

On average, without a doubt I found a difference working with them and receiving consults. Its to be expected.

 

Expected? That's made up BS.

 

The 5 year docs are much better at handling acuity, teaching students/residents, practicing and teaching evidence based medicine. They on average work their patients up better and more appropriately before referral.

 

Handling acuity? Please explain which patients are handled poorly.

Teaching students/residents? Ya, family docs obviously can't teach...

Practice and teach EBM? How does that STEMI make you feel? Any idea what caused that multi-trauma? Whats your expectation of managing your sepsis?

 

"On average" you're just making this up.

 

The 5 year guys deep down think they are superior the CCFP grads, although everyone is friendly in person. You can't blame them though because its on average true.

 

This is the most wrong: All 5 year residents think they are superior!

 

You're the anecdote...

 

Cute how you disguised your arguments at the end. It's just an average so some are better, and well some are worse. (Thanks for clarifying what it means when you say average!) And you're obviously totally 100% not biased and purely fact based because you're not one of them.

[BoyInTheBubble]

In our program, I don't think we really take note of which consulting ER docs are 5- vs 3- year graduates (unless something happens to make it a question of interest). The main variables surrounding an interaction seem to be 1) individual factors (personality, dedication, judgment, etc.) and 2) amount of experience (of course, the new 3-year grads have the least).

 

Unless you know the referring doc personally, you shouldn't know how they are trained.

 

Further, individual factors shouldn't play much of a role unless it's persuasiveness. Even experience doesn't matter. Imagine ignoring a consult because they got a med student to call your service. You base your decisions on patient factors. You're a fool if you think you have a leg to stand on in court by saying, well, your honour, you see he was a grumpy, poorly dedicated and inexperienced doctor who has showed bad judgement in the past, so we he said that Mrs Smith had X, Y, and Z, I thought he couldn't be right.

[Lactic Folly]

Further, individual factors shouldn't play much of a role unless it's persuasiveness. Even experience doesn't matter. Imagine ignoring a consult because they got a med student to call your service. You base your decisions on patient factors. You're a fool if you think you have a leg to stand on in court by saying, well, your honour, you see he was a grumpy, poorly dedicated and inexperienced doctor who has showed bad judgement in the past, so we he said that Mrs Smith had X, Y, and Z, I thought he couldn't be right.

 

Don't think we're referring to the same thing here. I was responding to the question of whether any differences between physicians are noted, which I took to mean the interaction in general, which of course depends on the personality etc. of the person you are dealing with.

 

You seem to be addressing the question of whether the identity of the physician affects one's decision to see a consult instead. In fact, when a consult comes from someone whose judgment is less trusted, most people I know have said they would make the effort to see the patient sooner and work them up more readily, since there is not that same confidence in knowing what is going on based on the conversation.

[BoyInTheBubble]

Don't think we're referring to the same thing here. I was responding to the question of whether any differences between physicians are noted, which I took to mean the interaction in general, which of course depends on the personality etc. of the person you are dealing with.

 

You seem to be addressing the question of whether the identity of the physician affects one's decision to see a consult instead. In fact, when a consult comes from someone whose judgment is less trusted, most people I know have said they would make the effort to see the patient sooner and work them up more readily, since there is not that same confidence in knowing what is going on based on the conversation.

 

Ya. I've experienced this. Adds a sense of urgency when something is missing or just feels 'off' on the phone call.

[thebouque]

There is no difference whatsoever clinically.

[The Journey Man]

Expected? That's made up BS.

 

 

 

Handling acuity? Please explain which patients are handled poorly.

Teaching students/residents? Ya, family docs obviously can't teach...

Practice and teach EBM? How does that STEMI make you feel? Any idea what caused that multi-trauma? Whats your expectation of managing your sepsis?

 

"On average" you're just making this up.

 

 

 

This is the most wrong: All 5 year residents think they are superior!

 

You're the anecdote...

 

Cute how you disguised your arguments at the end. It's just an average so some are better, and well some are worse. (Thanks for clarifying what it means when you say average!) And you're obviously totally 100% not biased and purely fact based because you're not one of them.

 

I think my comments may have aggravated a nerve. But I guess Ill try to reply in more detail to tell you what I mean.

 

Regarding teaching: Its not that the CCFP "cannot" teach. Its in my experience many didn't compared to the FRCPC docs I worked with. As in, the chose NOT to. I had wonderful experience with a couple CCFP docs that were great teachers, but I felt that many had no interest in it otherwise

 

Regarding emergency situations: a STEMI is by no means always obvious, and not all ST elevation requires you to activated code STEMI protocol. This requires a lot time and practice, especially through your CCU/Cardiology rotations. Its obvious that a FRCPC resident will be better because they spend much more time in Cardio/CCU seeing which cases were called correctly and which weren't.

 

Regarding EBM: When I was being taught, the 5 year trained docs would often quote the literature and tweaking my management plans with the best evidence at that time. This is something I did not get from other docs.

 

Managing sepsis: First it to be recognized, then appropriate source identified, appropriate antibiotics etc. You think this is simple, but its often either not done or inappropriately.

 

Regarding residents thinking they are superior: I did not say all. Its an observation. Its human nature. You spend 5 years doing something, and another person spends 1 year, now you two do the same job. What do you expect.

 

I kept on saying on average because obviously there are outliers. And I said its to be expected because thats the end result of 5 years of dedicated training vs 1 year of dedicated training. That doesn't mean CCFP docs are terrible or nobody trusts them, its just the FRCPC training gives you much more depth and breadth. What else do you think they're doing in those extra 4 years if there is no difference?

 

My comments were in no shape to belittle CCFP trained docs, rather make an observation for someone who has spent decent amount of time in multiple centres in ER and now training as a consultant to the ER. There are gaps in training in just 1 year. How can there not be? You can't spend more time off service on other rotations to learn from specialists like FRCPC grads. Its not enough time. But there are people who overcome them with continued learning and experience.

[BoyInTheBubble]

I was making a family medicine based 'FIFE' joke not asking for an obnoxious lesson. When you're talking on the phone or face to face with people in the emerge or anywhere in the hospital, do you often ask about their training?

 

Do you look down at all American ER docs too? Don't they train in 3 years (with some 4 year programs)?

 

Family docs don't start learning emergency medicine after finishing the two years. And the ones who do the third year have been focussing on it for most of the first two years anyways.

 

Do you get nightmares knowing that family docs can work in emerge without the third year?

 

Stating 'no offense' doesn't negate the ensuing insult. "in no shape to belittle ccfp" but for realsies they suck.

[The Journey Man]

I was making a family medicine based 'FIFE' joke not asking for an obnoxious lesson. When you're talking on the phone or face to face with people in the emerge or anywhere in the hospital, do you often ask about their training?

 

Do you look down at all American ER docs too? Don't they train in 3 years (with some 4 year programs)?

 

Family docs don't start learning emergency medicine after finishing the two years. And the ones who do the third year have been focussing on it for most of the first two years anyways.

 

Do you get nightmares knowing that family docs can work in emerge without the third year?

 

Stating 'no offense' doesn't negate the ensuing insult. "in no shape to belittle ccfp" but for realsies they suck.

 

It seems like you have a stake in this, and what I'm saying May be taken to mean something else.

 

We are comparing. I'm not saying they suck. But to ignore differences makes no sense. For someone who has 1 year of formal training under their belt to be as good as someone who has more, to acknowledge that there is a gap would be better because then you can at least work towards closing that gap. If you remain arrogant and state their are no differences then that won't help.

 

And yes it's kind of scary having people not formally trained in ER at all. Hopefully there will be more spots in training CCFP and frcpc spots so that doesn't remain an option.

 

We are focusing on ER here but happens in every field. We can see echo reports done from people done in the community who have leas formal training and these reports are repeatedly unreliable

Vs the academic cardiologists who have spent considerable time training in echo. Would anybody doubt that a cardiologist would be more reliable reading echo vs somebody bought themselves an echo machine? Sure there may be some people who are constantly working hard to be as good as cardiologist but on average most wouldn't be.

[BoyInTheBubble]

It seems like you have a stake in this, and what I'm saying May be taken to mean something else.

 

We are comparing. I'm not saying they suck.

 

My stake is irrelevant.

 

You are making up 'facts' that belittle the large majority of emergency doctors (since it's mostly done by family docs). They may be different to the 5 year docs, but that isn't defined by their ability to handle acuity, teach students and residents, or practice and teach ebm.

[thebouque]

It seems like you have a stake in this, and what I'm saying May be taken to mean something else.

 

We are comparing. I'm not saying they suck. But to ignore differences makes no sense. For someone who has 1 year of formal training under their belt to be as good as someone who has more, to acknowledge that there is a gap would be better because then you can at least work towards closing that gap. If you remain arrogant and state their are no differences then that won't help.

 

And yes it's kind of scary having people not formally trained in ER at all. Hopefully there will be more spots in training CCFP and frcpc spots so that doesn't remain an option.

 

We are focusing on ER here but happens in every field. We can see echo reports done from people done in the community who have leas formal training and these reports are repeatedly unreliable

Vs the academic cardiologists who have spent considerable time training in echo. Would anybody doubt that a cardiologist would be more reliable reading echo vs somebody bought themselves an echo machine? Sure there may be some people who are constantly working hard to be as good as cardiologist but on average most wouldn't be.

 

Drop it. They're the same clinically. If you're thinking otherwise you're in for a big reality check.

[Alastriss]

Drop it. They're the same clinically. If you're thinking otherwise you're in for a big reality check.

 

They are equal several years down the road and there's a study to back that. If you think a 5 year and a 2+1 are equal clinically fresh out of residency you are delusional. Nothing about being a GP it's about the length and focus of training. There's a reason why there are no fellowships open to 2+1s or why 5 years are preferred.

 

Not trying to start a flame war but people reading these posts need to realize that there is a difference at least in the starting years

[BoyInTheBubble]

They are equal several years down the road and there's a study to back that. If you think a 5 year and a 2+1 are equal clinically fresh out of residency you are delusional. Nothing about being a GP it's about the length and focus of training. There's a reason why there are no fellowships open to 2+1s or why 5 years are preferred.

 

Not trying to start a flame war but people reading these posts need to realize that there is a difference at least in the starting years

 

Perhaps. But all residents face a transition. First months out after finishing a 5 year program, you're competent but there are jitters associated with the fact that you are now ultimately responsible.

 

The major benefit to doing the 5 year emerge program is widely regarded as being mostly non-clinical. Most programs allow residents to do a masters or fellowship within the 5 years.

 

But the statements being made were about staff emerge docs. As in, they don't work up patients well, they don't teach residents and students well, etc which is simply not true.

[thebouque]

They are equal several years down the road and there's a study to back that. If you think a 5 year and a 2+1 are equal clinically fresh out of residency you are delusional. Nothing about being a GP it's about the length and focus of training. There's a reason why there are no fellowships open to 2+1s or why 5 years are preferred.

 

Not trying to start a flame war but people reading these posts need to realize that there is a difference at least in the starting years

 

A future internist and a future pathologist talking about the differences between the R3 and R5 path for EM, now that's funny

[A-Stark]

They are equal several years down the road and there's a study to back that. If you think a 5 year and a 2+1 are equal clinically fresh out of residency you are delusional. Nothing about being a GP it's about the length and focus of training. There's a reason why there are no fellowships open to 2+1s or why 5 years are preferred.

 

Not trying to start a flame war but people reading these posts need to realize that there is a difference at least in the starting years

 

But is there an actual reason why CCFP-EM docs can't pursue fellowships? Royal College trainees can begin fellowships in their PGY4. It's true they get a little more ICU/CCU than their CCFP-EM colleagues, but we're talking about the difference of maybe one block. It's still less than any medicine or anesthesia resident gets.

 

The artefact of different training paths in EM reflects disorganization in the specialty but not, I think, a whole lot else. The reason CCFP-EM can't pursue Royal College subspecialty fellowships is that they lack Royal College specialty certification. There isn't any good reason for this.

[Alastriss]

A future internist and a future pathologist talking about the differences between the R3 and R5 path for EM, now that's funny

 

Perhaps once upon a time we considered both of these options, and perhaps once upon a time we talked to people who have a strong and valid opinion about this. Furthermore, Just because you aren't in either program doesn't mean your opinion is less valid.

 

It's inappropriate for you to say that 2+1 and 5 year ER are equal on all fronts on these forums because this is a question that's highly debated and a lot of med students come here for answers. I myself was one of them, and I had to go out and seek the answers myself from truly knowledgeable people, which is what I'm bringing back my post saying that from the get-go 5 year has a clinical edge + fellowship and job prospect advantages over a 2+1 but these even out over the years as clinical experience is gained.

[Alastriss]

But is there an actual reason why CCFP-EM docs can't pursue fellowships? Royal College trainees can begin fellowships in their PGY4. It's true they get a little more ICU/CCU than their CCFP-EM colleagues, but we're talking about the difference of maybe one block. It's still less than any medicine or anesthesia resident gets.

 

The artefact of different training paths in EM reflects disorganization in the specialty but not, I think, a whole lot else. The reason CCFP-EM can't pursue Royal College subspecialty fellowships is that they lack Royal College specialty certification. There isn't any good reason for this.

 

The different training paths has a bit of a history to it, I remember vaguely hearing about this but can't comment further.

 

It's a function of not being a royal college as you said, but there are many other royal college specialties that don't have direct entry into ICU like ER does. The fact that ER is one of the fastest ways (second to IM) to do ICU and is one of the 4 specialties that can pursue it before completing their entire residency shows you that they've been trained more in dealing with acute medical care. For other specialties other than General surgery, EM, IM, and anes, you must complete your residency before you apply (cardiac sx, neurosx, etc)

 

It's so simple, take a look at the CCFP 2+1 and the 5 year ER program, and forget the 4th year "MSc" year there. There's easily more training in that 5 year program than there is in a 2+1, even if you can manage to rack up all your electives in ER (and this is not always the case as it depends on your school's family medicine program and how many electives it affords you). It's not about being a family doctor it's just about having less training than your counterpart in the early years of free practice. Again, this is NOT about FAMILY DOCS not being able to do ER. As mentioned before, all that evens out in the end.

 

In a similar fashion, the 4 year GIMs will now (likely) experience a similar issue with the new 3+2 year fellowship GIM programs that are being offered.

 

This is all important in the sense that whoever is reading this thinking about 2+1 vs 5 year, think about where you want to work, what setting you want to work in, academic vs community, etc and make your decision based on that. You can get jobs so far in either setting but easier with 5 year (unless you are going to VGH, where they only hire 5 year docs now).

[Byrne]

They are equal several years down the road and there's a study to back that. If you think a 5 year and a 2+1 are equal clinically fresh out of residency you are delusional. Nothing about being a GP it's about the length and focus of training. There's a reason why there are no fellowships open to 2+1s or why 5 years are preferred.

 

Not trying to start a flame war but people reading these posts need to realize that there is a difference at least in the starting years

 

As someone interested in EM, I often hear this several years down the road "study" referenced when folks get into the FRCPC vs. CCFP-EM debate. However, my understanding is that this "study" originates from what was a series of opinion pieces following the publication of a controversial Canadian Association of Emergency Physicians newsletter. Those interested can actually read the original newsletter (from fall 1997) and the many subsequent pieces that have since followed here: http://caep.ca/sites/default/files/caep/files/dual_college_-_dual_certification__historical_timeline_1997-2010.pdf

 

I think BoringEM, which is run by a current year 4 FRCPC resident at the University of Saskatchewan, wrote a great piece on this topic: http://boringem.org/2013/05/27/frcpc-or-ccfp-em-what-is-best-for-you/

[Alastriss]

As someone interested in EM, I often hear this several years down the road "study" referenced when folks get into the FRCPC vs. CCFP-EM debate. However, my understanding is that this "study" originates from what was a series of opinion pieces following the publication of a controversial Canadian Association of Emergency Physicians newsletter. Those interested can actually read the original newsletter (from fall 1997) and the many subsequent pieces that have since followed here: http://caep.ca/sites/default/files/caep/files/dual_college_-_dual_certification__historical_timeline_1997-2010.pdf

 

I think BoringEM, which is run by a current year 4 FRCPC resident at the University of Saskatchewan, wrote a great piece on this topic: http://boringem.org/2013/05/27/frcpc-or-ccfp-em-what-is-best-for-you/

 

Yet there are some program directors who will draw a bigger gap between the two than what BoringEM has specified. I'll add to his list that certain fellowships (ICU a big one, for example, and I BELIEVE toxicology) can't just be made into a 'niche' as a CCFP EM. You will need to do a fellowship to actually work those roles.

 

With that said, several academic institutions will keep their own. Mt. Sinai will hire their 2+1s because that's in a way 2+1 'central' as far as UofT goes. UWO hired CCFP EMs a few years back from a resident I talked to.

[Satsuma]

As someone interested in EM, I often hear this several years down the road "study" referenced when folks get into the FRCPC vs. CCFP-EM debate. However, my understanding is that this "study" originates from what was a series of opinion pieces following the publication of a controversial Canadian Association of Emergency Physicians newsletter. Those interested can actually read the original newsletter (from fall 1997) and the many subsequent pieces that have since followed here: http://caep.ca/sites/default/files/caep/files/dual_college_-_dual_certification__historical_timeline_1997-2010.pdf

 

I think BoringEM, which is run by a current year 4 FRCPC resident at the University of Saskatchewan, wrote a great piece on this topic: http://boringem.org/2013/05/27/frcpc-or-ccfp-em-what-is-best-for-you/

 

You are right, the 1997 piece does get thrown around as some kind of fact when these discussions occur. And it's kind of silly. It was more of a question posed without any conclusions. It was not a scientific study. And it wasn't even commenting on skill level, but rather practice patterns. So 10 years out the careers of the +1s and the FRs looked alot alike.

 

The intention when the 2 routes of certification were developped, was that the +1s would combine EM and FM, and that the FRs would be involved in such things as research to advance the specialty. But they comment that many +1s only do EM, and the FRs only do clinical work. So, there's no difference 10 years out.

 

Somehow that got extrapolated and people talk about this "opinion piece" as though it was research paper that scientifically examined the skill levels of +1s and FRs and that the conclusion was that 10 years out they are the same.

 

But, that isn't the case.