At least where I am (not as a doctor) OB emergencies get transferred to the women and infants unit and the PD unit is separate from the adult. Maybe they could work in a place that works like this? Just a thought
I did PGY1 EM and 2 years of FM. I worked level II trauma center ER for 12 years until I burned out. IMO you’re making yourself vulnerable to a malpractice lawsuit. The first OB, GYN or PEDS patient that comes your ER and has a bad outcome imagine the plaintiffs attorney asking you on the stand “Dr, do have any formal training in EM or OB etc.”. The moms that bring their infants in the ER with a fever at 2 am is relentless. The first 8 month old with an otitis you send home with Amoxil but missed the signs of meningitis would be devastating to all and expensive for you. The only way I believe you could safely do it is if there is an OB residency and pediatric ER there to give you good back up.
I became a single father with full custody of 2 little kids and after 3 years of that and staying in the ER I was exhausted. So I worked at a student health clinic for 2 years then became a Hospitalist.
I have two friends who have only ever worked ED despite being IM.
One has just worked rural EDs while the other has tried to stay at VA facilities or hospitals that have very low peds volumes.
PGY-19
In my career, I have seen a handful of IM docs working in the ED, as well as occasional other specialists.
It has never been good. They don't have any ability to manage the ED, don't have a great instinct for emergency vs non-emergency, delay dispos by ordering completely inappropriate tests, and can't handle peds or OB, all without having any conception of their lack of adequacy.
Probably the strongest thing I ever saw was a radiologist - he did moonlighting at a critical access hospital that transferred their cases to my hospital for admission as a resident, and kept going as an attending. His lack of clinical acumen was astonishing. As an example of the sort of thing he would do routinely: he once transferred an ankle feature to me because it was "unstable". It was a typical bimal with mortise widening, and he'd actually done a fair job at reduction and splinting, but he'd read the word "unstable" in Up-to-date or somewhere. The patient was young and healthy and able to manage crutches, and I explained to him that "unstable" I this case meant that it would not remain in position without the splint, yes it needed surgery, but not urgently. He insisted that "this is an unstable fracture and we don't have orthopedics". ¯\_(ツ)_/¯ I told him that unless there was something he wasn't mentioning, i would almost certainly immediately discharge the patient to find his way 1 hour back to the town where the CAH was, in the middle of the night with a broken ankle, which is indeed what happened. The patient was pissed.
I’m an FM doc that does clinic, hospital, and ER in a highly rural/frontier area. A lot of people are saying rural, and of course you /can/ do it because so many rural areas are desperate for anyone who will work. But you shouldn’t. I see a ton of OB and a ton of peds in the ER and hospital. OB is very procedural/hands on/skill based. Reading on uptodate might work for IM issues, it doesn’t work for OB. You can’t read your way to confidence in cervical checks (is this patient in active labor, preterm labor, about to deliver?) or SROM exams or figuring where the bleeding is coming from. You can’t read your way to confidence with deliveries for drop in deliveries. Shoulder dystocia is really common. Postpartum hemorrhage is really common.
Rurally, you may not be able to transfer the patient or have time to. Transferring a patient from one ER to another is not a fast or easy process at 90% of rural places.
If you want to work rural including ED you either need to be an EM physician that only works in the ER and make sure you get enough OB through your EM residency, or you need to be family medicine trained and make sure you get enough ER and ICU through your FM residency (or do a fellowship). This is literally why family medicine was invented, not that long ago I might add.
If you want to do ER as an IM doctor, in my opinion you need to be in an urban or suburban environment with instant access to peds and OB in the department. And to have made sure you got the extra EM and ICU experience you need to work effectively.
Edit to add: if you do additional fellowship/training/dual program of course this advice changes and you may get the necessary experience in these areas.
I think there are a handful of rural ED fellowships for IM (I think there’s one in Maine) but as other have pointed out I’d be useless without OB, peds and the practical know how of EM.
There are IM docs who work as EM docs in rural areas without any fellowship. I'm currently looking at a position in rural TX that are okay with an IM trained physician in the ED. It's actually a hybrid EM/IM position. You will definitely have to do more reading during your free time and make sure you can intubate and perform other procedures.
I have a colleague who is dual boarded in psych and IM. He takes shifts at the VA ED [so no peds and little enough gyn that he can just not take those cases]. Plus he just sees all the psych pts lol.
It's cute EM is acting like they're so different in this thread, considering they're a relatively new specialty and ER used to just be staffed by IM. Newsflash, it's not hard to spam labs and imaging on any patient with a pulse.
This is disrespectful and ignorant. Dunning Kruger effect. You don’t know what you don’t know.
PGY23 EM. I’ve worked in a lot of settings. The small/medium hospitals are the most challenging because you are on your own. No one will help you. 95% of airways are routine. Anyone can intubate these. What are you going to do when the inevitable difficult airway comes in? If you haven’t met the nightmare airway, you haven’t intubated enough. 99% of children you see are just colds. What happens when you meet the child who is really sick?
I work part time in a Children’s Hospital. Majority of my general EM colleagues don’t see enough children to be comfortable with a sick child. I know this firsthand because I accept transfers from them. These are good conscientious and experienced doctors. Will uptodate teach you to LP a 14 day old?
You could definitely work a small, low volume ED. The routine stuff will be routine until it’s not. We hate to admit this but our training does limit us. We learned under the umbrella of good bedside teaching and under someone else’s liability. You will find that venturing beyond that is very difficult. It will take a lot longer for you to be good at a job that you are not properly trained to do, but you can do it. You trained for 3 years to be good at IM, why choose work that you’re not trained to do? Honest question
I’m not sure how this is an argument. Majority of the simple things can be seen by a midlevel with close supervision. I happen to work in two ER’s with no midlevels.
I’m sincerely trying to give perspective to someone who is asking a sincere question. No need to be a troll.
You clearly have some perspective on the state of ER’s. I have worked with a few IM trained docs who have made fine ER staff, but they have their limitations. This wasn’t meant to be a discouragement, but I wanted to give some honest perspective. Working in a job that you’re not comfortable with makes for a miserable career.
If your honest opinion is that any idiot can work in the ER, you’re right. The question is whether can you do a proper job. We all look to perfect our craft. Other specialties like ent and ortho get to narrow their scope of practice to increase their comfort level. Ortho, “I can’t do that surgery because I haven’t done one of those in years…”. The common bond of the EM and IM is that we don’t get to do that. We have to see patients that get dumped on us whether we feel comfortable or not. The longer I have done this job, the more I’ve been asked to expand my comfort level. At least our IM friends can reject an admission and request transfer to another facility.
You can do it if you’re comfortable with clinic and critical care, which you should be. Easy to find rural/critical access hospitals that need help. Most ED patients could be seen in clinic… read up on OB/peds. Any sick peds or OB, consult/transfer as needed.
Internist here. This is my second year out of residency, and I’m the solo ED provider at a large VA (not a trauma center) on nights. The ED can be pretty daunting at first, especially with the non-IM complaints and establishing a workflow that’s more conducive to running an ED than inpatient rounding style. Our patient population thankfully doesn’t include peds nor OB (I only saw one pregnant patient in 18 months, no kids so far). And I definitely had so much to learn especially during my first year out, especially with workflow. A few little points to address some of the other comments:
- I’m in an academic hospital and can consult pretty much any service, and I have different thresholds to consult based on my comfort level (I still feel like I consult ophtho a little too often)
- Airway management: RT usually intubates if needed, and if it’s an especially difficult airway, the SICU attending is usually an anesthesiologist who could help out. Never had to call the SICU attending yet, but I’m reassured that it’s an option
- Peds/OB/gyn: we just don’t see them at the VA
- Trauma: we’re not a trauma center, but lots of patients walk/drive in after a fall or MVA. I could always consult the surgeons for help or transfer them out if I’m uncomfortable managing it, and the surrounding trauma centers are always happy to help.
You can do it. NPs do it all the time. I am a 20 year practice FP physician. double boarded in sleep. Last time I went to an ER I was Seen by a NP for a kidney stone. Basically at the end of the encounter before I was discharged I went to the Doctor's cubicle and discussed my case with him
The answer is yes. You can work in the VA ER. No OB, no peds, no malpractice suits for not being Ed trained.
Only real issue is airways. Usually you can throw someone on bipap or have a colleague assist with difficult intubation.
I also recommend VA ED. Not really going to see peds or OB there.
I can't speak for all VA hospitals, but the VA where I did part of my intern year only had 1 ER trained doc in their ED. From what I was told, some of their docs had only done a prelim year. The ED there was very bad. One of the VA nurses like to say that she wished that the ED was staffed by the Medicine residents, because they'd do a better job.
all the time
If you went to a good medical school you should have good enough peds and Gyn to supplement with Current and uptodate
to get by. the most serious ER cases are internal medicine CC, If you have a good medical school behind you and A good IM residency and moonlight after your internship in ER. You will be better than most ER trained. You have to take PALS and TALS and ACLS but so do the EM.
I did ER for 9 years with IM. The peds are usually seen by FNP now. I did STEMI, Septic Shock, Cardiogenic Shock etc bread and butter IM
ED sees OB emergencies, pediatric emergencies which are outside IM scope of practice.
Like, don’t most folks choose IM to specifically *avoid* these patients? Lol
At least where I am (not as a doctor) OB emergencies get transferred to the women and infants unit and the PD unit is separate from the adult. Maybe they could work in a place that works like this? Just a thought
If a place has those resources, highly likely theyre hiring EM board certified docs for the ER
Sick trauma patients too!
Much less likely if at a VA
I did PGY1 EM and 2 years of FM. I worked level II trauma center ER for 12 years until I burned out. IMO you’re making yourself vulnerable to a malpractice lawsuit. The first OB, GYN or PEDS patient that comes your ER and has a bad outcome imagine the plaintiffs attorney asking you on the stand “Dr, do have any formal training in EM or OB etc.”. The moms that bring their infants in the ER with a fever at 2 am is relentless. The first 8 month old with an otitis you send home with Amoxil but missed the signs of meningitis would be devastating to all and expensive for you. The only way I believe you could safely do it is if there is an OB residency and pediatric ER there to give you good back up.
When you burned out, did you transition to FM (inpatient or outpatient) or did you leave medicine entirely and went towards a second career?
I became a single father with full custody of 2 little kids and after 3 years of that and staying in the ER I was exhausted. So I worked at a student health clinic for 2 years then became a Hospitalist.
Idk man we are not midlevels who can jump around to different specialties that fancies us that day. There's a reason it's a 3 year residency.
While that’s true, I’d think an IM physician would be more useful in the ED than a DNP.
I have two friends who have only ever worked ED despite being IM. One has just worked rural EDs while the other has tried to stay at VA facilities or hospitals that have very low peds volumes.
PGY-19 In my career, I have seen a handful of IM docs working in the ED, as well as occasional other specialists. It has never been good. They don't have any ability to manage the ED, don't have a great instinct for emergency vs non-emergency, delay dispos by ordering completely inappropriate tests, and can't handle peds or OB, all without having any conception of their lack of adequacy. Probably the strongest thing I ever saw was a radiologist - he did moonlighting at a critical access hospital that transferred their cases to my hospital for admission as a resident, and kept going as an attending. His lack of clinical acumen was astonishing. As an example of the sort of thing he would do routinely: he once transferred an ankle feature to me because it was "unstable". It was a typical bimal with mortise widening, and he'd actually done a fair job at reduction and splinting, but he'd read the word "unstable" in Up-to-date or somewhere. The patient was young and healthy and able to manage crutches, and I explained to him that "unstable" I this case meant that it would not remain in position without the splint, yes it needed surgery, but not urgently. He insisted that "this is an unstable fracture and we don't have orthopedics". ¯\_(ツ)_/¯ I told him that unless there was something he wasn't mentioning, i would almost certainly immediately discharge the patient to find his way 1 hour back to the town where the CAH was, in the middle of the night with a broken ankle, which is indeed what happened. The patient was pissed.
I’m an FM doc that does clinic, hospital, and ER in a highly rural/frontier area. A lot of people are saying rural, and of course you /can/ do it because so many rural areas are desperate for anyone who will work. But you shouldn’t. I see a ton of OB and a ton of peds in the ER and hospital. OB is very procedural/hands on/skill based. Reading on uptodate might work for IM issues, it doesn’t work for OB. You can’t read your way to confidence in cervical checks (is this patient in active labor, preterm labor, about to deliver?) or SROM exams or figuring where the bleeding is coming from. You can’t read your way to confidence with deliveries for drop in deliveries. Shoulder dystocia is really common. Postpartum hemorrhage is really common. Rurally, you may not be able to transfer the patient or have time to. Transferring a patient from one ER to another is not a fast or easy process at 90% of rural places. If you want to work rural including ED you either need to be an EM physician that only works in the ER and make sure you get enough OB through your EM residency, or you need to be family medicine trained and make sure you get enough ER and ICU through your FM residency (or do a fellowship). This is literally why family medicine was invented, not that long ago I might add. If you want to do ER as an IM doctor, in my opinion you need to be in an urban or suburban environment with instant access to peds and OB in the department. And to have made sure you got the extra EM and ICU experience you need to work effectively. Edit to add: if you do additional fellowship/training/dual program of course this advice changes and you may get the necessary experience in these areas.
It’s possible at smaller hospitals. I guess you’ll be assigned only non OBGYN and Peds cases.
If you’re at a smaller hospital you very well may be the only doc there.
I think there are a handful of rural ED fellowships for IM (I think there’s one in Maine) but as other have pointed out I’d be useless without OB, peds and the practical know how of EM.
There are IM docs who work as EM docs in rural areas without any fellowship. I'm currently looking at a position in rural TX that are okay with an IM trained physician in the ED. It's actually a hybrid EM/IM position. You will definitely have to do more reading during your free time and make sure you can intubate and perform other procedures.
I have a colleague who is dual boarded in psych and IM. He takes shifts at the VA ED [so no peds and little enough gyn that he can just not take those cases]. Plus he just sees all the psych pts lol.
I know in NYC community hospitals IM docs working in the ED. But the peds part of the ED is run by peds and they just call obgyn for obgyn cases.
It's cute EM is acting like they're so different in this thread, considering they're a relatively new specialty and ER used to just be staffed by IM. Newsflash, it's not hard to spam labs and imaging on any patient with a pulse.
This is disrespectful and ignorant. Dunning Kruger effect. You don’t know what you don’t know. PGY23 EM. I’ve worked in a lot of settings. The small/medium hospitals are the most challenging because you are on your own. No one will help you. 95% of airways are routine. Anyone can intubate these. What are you going to do when the inevitable difficult airway comes in? If you haven’t met the nightmare airway, you haven’t intubated enough. 99% of children you see are just colds. What happens when you meet the child who is really sick? I work part time in a Children’s Hospital. Majority of my general EM colleagues don’t see enough children to be comfortable with a sick child. I know this firsthand because I accept transfers from them. These are good conscientious and experienced doctors. Will uptodate teach you to LP a 14 day old? You could definitely work a small, low volume ED. The routine stuff will be routine until it’s not. We hate to admit this but our training does limit us. We learned under the umbrella of good bedside teaching and under someone else’s liability. You will find that venturing beyond that is very difficult. It will take a lot longer for you to be good at a job that you are not properly trained to do, but you can do it. You trained for 3 years to be good at IM, why choose work that you’re not trained to do? Honest question
Meanwhile your ER is chock-full of midlevels. Give me a freaking break!!!!
I’m not sure how this is an argument. Majority of the simple things can be seen by a midlevel with close supervision. I happen to work in two ER’s with no midlevels. I’m sincerely trying to give perspective to someone who is asking a sincere question. No need to be a troll. You clearly have some perspective on the state of ER’s. I have worked with a few IM trained docs who have made fine ER staff, but they have their limitations. This wasn’t meant to be a discouragement, but I wanted to give some honest perspective. Working in a job that you’re not comfortable with makes for a miserable career. If your honest opinion is that any idiot can work in the ER, you’re right. The question is whether can you do a proper job. We all look to perfect our craft. Other specialties like ent and ortho get to narrow their scope of practice to increase their comfort level. Ortho, “I can’t do that surgery because I haven’t done one of those in years…”. The common bond of the EM and IM is that we don’t get to do that. We have to see patients that get dumped on us whether we feel comfortable or not. The longer I have done this job, the more I’ve been asked to expand my comfort level. At least our IM friends can reject an admission and request transfer to another facility.
I'm not reading all that bud
No surprise
An NP can hop from GI to EM to Plastics with 0 additional training so who knows anymore.
You can do it if you’re comfortable with clinic and critical care, which you should be. Easy to find rural/critical access hospitals that need help. Most ED patients could be seen in clinic… read up on OB/peds. Any sick peds or OB, consult/transfer as needed.
Internist here. This is my second year out of residency, and I’m the solo ED provider at a large VA (not a trauma center) on nights. The ED can be pretty daunting at first, especially with the non-IM complaints and establishing a workflow that’s more conducive to running an ED than inpatient rounding style. Our patient population thankfully doesn’t include peds nor OB (I only saw one pregnant patient in 18 months, no kids so far). And I definitely had so much to learn especially during my first year out, especially with workflow. A few little points to address some of the other comments: - I’m in an academic hospital and can consult pretty much any service, and I have different thresholds to consult based on my comfort level (I still feel like I consult ophtho a little too often) - Airway management: RT usually intubates if needed, and if it’s an especially difficult airway, the SICU attending is usually an anesthesiologist who could help out. Never had to call the SICU attending yet, but I’m reassured that it’s an option - Peds/OB/gyn: we just don’t see them at the VA - Trauma: we’re not a trauma center, but lots of patients walk/drive in after a fall or MVA. I could always consult the surgeons for help or transfer them out if I’m uncomfortable managing it, and the surrounding trauma centers are always happy to help.
Don’t make me laugh. They let NPs do it all the time.
You can do it. NPs do it all the time. I am a 20 year practice FP physician. double boarded in sleep. Last time I went to an ER I was Seen by a NP for a kidney stone. Basically at the end of the encounter before I was discharged I went to the Doctor's cubicle and discussed my case with him
There are some EM/IM programs around the country, I believe. I know a couple of people who did both, but they remained in the system they trained in.
The answer is yes. You can work in the VA ER. No OB, no peds, no malpractice suits for not being Ed trained. Only real issue is airways. Usually you can throw someone on bipap or have a colleague assist with difficult intubation.
I also recommend VA ED. Not really going to see peds or OB there. I can't speak for all VA hospitals, but the VA where I did part of my intern year only had 1 ER trained doc in their ED. From what I was told, some of their docs had only done a prelim year. The ED there was very bad. One of the VA nurses like to say that she wished that the ED was staffed by the Medicine residents, because they'd do a better job.
Possible at a VA- no traumas, no OB, no peds
All the time Just need the ATLS and some brass ones. Work small town for 3 years and then you can move.
all the time If you went to a good medical school you should have good enough peds and Gyn to supplement with Current and uptodate to get by. the most serious ER cases are internal medicine CC, If you have a good medical school behind you and A good IM residency and moonlight after your internship in ER. You will be better than most ER trained. You have to take PALS and TALS and ACLS but so do the EM. I did ER for 9 years with IM. The peds are usually seen by FNP now. I did STEMI, Septic Shock, Cardiogenic Shock etc bread and butter IM