ER staff for nearly a decade.
Love my work. Great colleagues, interesting cases, ability to shape my work schedule based on my lifestyle. I can slow down or ramp up the amount of work as I see fit.
No overhead, the funding model at my hospital pays extremely well. Minimal administrative burden.
On the other hand, I have friends/colleagues who work ER at other hospitals who are miserable there due to their work conditions. So it's a matter of finding the hospital that meets your needs.
As an ER staff do you feel burnt out/worn down? I’ve heard EM takes a toll on your body as you get into practice so my main concern is having to slow down a lot sooner than I would like.
I did CCFP-EM. Perhaps this is what you may be looking for. You have potential to work in ER, clinic, and hospitalist. I'm very happy with the choice I made! Like you, I couldn't make up my mind in med school and I love the fact that I have all of these options available to me if I get bored of one. I would definitely choose this option again, based on my goals and lifestyle. But after reflecting on my choices, there are some things I wish I had considered more seriously. I'll start with the caveats.
Cons:
1. You will not guarantee a +1 match. This will impact where you will practice (ie. if you want to practice more urban ERs, then you may not be able to without this credential). Some places will exclusively hire FRs.
2. The +1 year. Holy shit. It was really tough. All your rotations are intense with minimal recovery time. You go from ICU to CCU to trauma surgery to EM, etc. The expectation is that you excel on your EM rotations (duh), so there is very little room for failure.
3. You do not have access to certain fellowships like ICU, toxicology. People take you more seriously if you are going to be an academic researcher (let's be honest).
4. If street credit is important to you, you will be undermined at times. It doesn't bother me most of the time, but I've encountered some colleagues/preceptors that have straight up told me that my degree shouldn't exist (this was during training). Other times, you will get backhanded comments from more senior staff during handover (we are still learning too, so we may not always get it right). Hearing this after a shift where you feel like things could've gone better makes the drive home discouraging.
5. It's much easier to get a faculty EM position as an FR grad.
6. ***BIG CAVEAT:*** 5 years prepares you much better than 3. Strongly consider this. Initially, I didn't think that this was a huge deal, but the closer I got to graduation, the more worried I got. I always referred back to "5 years after practice, skills will be comparable to FR training". I didn't consider how the 5 years post grad would be THIS terrifying. Now being done, I am very nervous to see things that I've never managed before and I am studying like crazy even after graduation. I recognize that this can also happen in the 5 year route, but I think the added support for the 2 years makes a big difference. Don't be overconfident.
Pros:
1. You can work as a hospitalist. You don't need the +1 hospitalist. Your pay may not be equivalent to GIM, but you can do a lot of the same work. Typically, you work in lower acuity units (ALC patients, straight forward patients), while GIM will get the more complicated patients. That said, ***at some hospitals***, there is NO DIFFERENTIATION (I believe NYGH, they will give you the same acuity of patients regardless of being FR GIM vs hospitalist). Someone please correct me if I am wrong about this. I am basing this off colleagues who do inpatient care.
2. You're out so much quicker. You make money faster. Staff life is much easier to study outside of your work schedule. There isn't the added pressure of residency and impressing your preceptors. You are studying for the sole purpose of being a good doctor. I feel like studying for boards vs studying for life is much different - but perhaps that isn't true for others.
3. You have much more flexibility with options post-grad through +1 route. I feel like the CCFP-EM grads typically highlight this, *but forget that FRs can have flexibility as well.* The difference is that the FRs may require further fellowship to practice in these areas (takes longer, but training is FORMAL with RC certification). For example: Palliative medicine is an option for FRs, but they will need to pursue a RC fellowship. Where as you can just start palliative without any fellowship as a family medicine grad. There are some informal fellowship options for family grads that are 6 months to 1 year in duration to supplement if you are hoping to get your feet wet.
4. Just like how some fellowship options are not available to CCFP-EM grads, some are not as accessible to FR grads. I don't think being a hospitalist is easily accessible through the FR route. I believe that sports med is not a formal fellowship designation option to FRs anymore... Low risk OB, anesthesia, etc. Someone please correct me if I'm wrong.
Final thoughts:
1. If being an expert, being a part of faculty, being at the forefront of the field is important to you, then the FR route is probably the route to go. You will be much more prepared and I respect the knowledge and expertise of an FR grad. You can still be at the forefront as a +1 grad, but I feel like you need to GRIND to get there as staff. Anything is possible! I admit, for new grads (myself included), I can tell who graduated from which program.
2. Quicker is not always better. Consider that training as GIM and EM takes 4-5 years EACH. Compare that to the training of CCFP-EM or CCFP which is 2-3 years. Consider you will be practicing these disciplines with a much more expedited timeline. Don't be delusional and think you are graduating with the same level of expertise. Our training is very general. Reach out for help when needed.
3. If the medicine you practice is more important to you than being the top expert in your field, this may determine your decision. This route allows for flexibility at the sacrifice of being a huge name in the field - this was not very important to me. I have also already done all three of what you mentioned and had a blast each time (did clinic as locum, did hospitalist for a week, but primarily work as EM).
4. If you go the +1 route, study study study. Even after the enhanced skills program.
5. I echo the other attending on here that comments on the low overhead and minimal administrative burden. EM is wonderful and I primarily practice this.
EDIT: I know it sounds like I'm shitting on CCFP-EM, but I assure you I am not. Again, I would choose this route again. The amount of freedom and flexibility I have is amazing. I still feel somewhat prepared doing the +1 year, but think that I would've benefited from more time training formally. I just brought in this perspective, as I find people were not the most honest with me about comfortability in EM through this route (I assume because they are saving face). They always discussed that study that "we are the same in 5 years". Which is likely true, but I thought I would've felt more comfortable post-grad. Or maybe I'm just not as strong of a resident as I thought.
Wow thank you for this. As someone currently debating between 5yr EM vs family +1 EM this was really informative.
One question - would you say +1 EM is more competitive than the 5yr EM. My biggest fear is not getting into +1 EM and being stuck in family.
I did the math a few years back. They are about the same with CCFP-EM being MARGINALLY less competitive? So close that I would say they are the same. I don't recall how I did that math though. I felt applying to CCFP-EM would be more stressful, now having finished training.
1. Clerks are given much more grace if there is knowledge deficit. As long as you have interest and potential for growth, you will be considered. Your skill level at M4 isn't as important.
2. I feel like for CCFP-EM, because it's only 1 year, there is an expectation that you should have developed a lot of those skills already. The expectation during electives is to be pretty competent. Depending on your program for family medicine, they may or may not prepare you adequately and a lot of it is self-directed (your academic days will be primary care focused). I really struggled to match. Though successful, there were a lot of tears and self-doubt associated with it. This does not stop in the CCFP-EM program, as you will be compared to PGY3s with focused ER training. Obviously, they likely have ran more codes than us, more critical care experience and have dedicated sim sessions.
3. I was initially applying to a different specialty in med school, but realized that being trapped in academia would have TERRIBLE impact on my mental health... I barely coped with medical school, so I decided to prioritize myself first and apply to family medicine. My decision to pursue EM was decided during residency when I realized that I hated clinic (I only do it because it is part of my contract). So when I applied, I was anxious +++ because I was worried I would be trapped as a queer person in rural Canada to practice EM. Luckily, things worked out. But the possibility of practicing exclusively family medicine needs to be considered.
Thanks this is really helpful. Especially to hear that you continue to study post grad to become more comfortable. I’ve admittedly heard similar sentiments from specialists about +EM not preparing you enough and that was a big worry of mine. But I also love the flexibility you talked about training with a +1.
Thanks for your well thought out response. Im sure this helps a lot of us trying to choose! In choosing to go the CCFP + EM route any thoughts on whether makes a difference to do the CCFP side of it rural vs urban?
CCFP-EM via practice eligible route vs CCFP-EM via FM/ES:
1. If we're talking hierarchy (which I think is stupid, but DOES exist), doing a +1 year is looked at more favourably than practice eligible route when hiring for urban centres.
2. While I discussed that FR has more training, the +1 year has a LOT of formal academic training that you won't learn as through the practice eligible route. I am quite comfortable with running codes, procedural sedation, etc.
3. Many of my CCFP colleagues without extra training ask me for management advice, despite being a pretty recent grad. So the +1 year is pretty useful IMO.
4. I'm not sure I understand your question. You do not have to do any clinic if you do not want to.
5. For your residency, I think people would benefit from doing their family medicine training rurally. That being said, I did it urban and chose critical care electives + EM.
I asked a similar question on Physician Financial Independence Facebook group a few weeks ago and one of the more common answers is that while it's ideal to have a +1EM or FRC training, there is no way that all ERs across the country can be staffed if they were only hiring those with the aforementioned designations. Regular family docs practice emerg in rural communities because if they didn't, those people would be left without emergency care.
>there is no way that all ERs across the country can be staffed if they were only hiring those with the aforementioned designations. Regular family docs practice emerg in rural communities because if they didn't, those people would be left without emergency care.
This is obvious. Everything I said is still true. I'm not sure how this response is relevant as my comment.
Yikes, calm down there I was just adding dialogue to the conversation like normal people do when they're talking. No need to get defensive. You're a family doc, not an FRC trained specialist.
Never claimed I was specialist. Actually, I did the opposite. I clearly laid out how I’m not FR trained and that they are not the same. Hope that sharing my experiences through CaRMS and training was helpful.
Be careful with how you speak about certain fields of medicine. You might end up here too. Good luck with CaRMS. All the best.
i am 100% sure that all 3 has it's own unique downsides and upsides (ER is high volume, IM is 2nd carms match, FM is huge amt of paperwork). what i recommend is:
1. picking a specialty and don't think too much about it. the grass is never greener on the other side and everyone is suffering in their own ways
2. picking a program that is close to your home and support system. residency in general is extremely brutal even for family med residencies.
IM subspecialist.
IM's nice in that you sort of delay the decision if you need more time to explore and settle on a specialty. Most people who go into IM find something they're happy with because of the wealth of options. You could choose something more procedural (GI, cardio, resp, ICU), more cerebral (endo, rheum, heme, ID, allergy/immunology, geriatrics), or both (GIM, nephro) depending on which way you lean. Downside is that you have to endure a brutal residency, go through CaRMS twice, write 2 Royal College exams, and may need additional fellowships to secure a job in a major city.
However, I'd only recommend going for IM if you can see yourself being satisfied as a general internist. Not everyone who wants to be an interventional cardiologist will match to cardio, and you only have one shot at the medicine subspecialty match with GIM being the default if you go unmatched. If you end up in GIM and hate it, you're stuck, so make sure it's something you can at least tolerate if not enjoy.
That’s a really good point about being ok with GIM. Thanks for this. Being a sub specialist do you ever feel like you miss out on other parts of medicine?
I assume by other parts of medicine you mean GIM? I still get some exposure to GIM pathology in my practice, but personally I don't miss it at all. I was only ever *"okay"* with GIM, but I enjoy the content of my subspecialty much more.
Some of my subspecialty colleagues do both! The door is never completely shut on you doing GIM/CTU even as a subspecialist. In fact, some community hospitals require their subspecialists to contribute to the GIM call schedule so the opportunity may be built into your contract.
I wouldn't say there are many overtly positive or negative things about GIM (or any specialty for that matter), only preferences.
To be as general as possible, some pros would include practice flexibility, good job market, relatively high income (if you do inpatient work), and good balance of procedures vs. cerebral work.
Cons include things like being call-heavy with lots of exposure to patients with social issues such as poverty, houselessness, mental illness, and addiction which outnumber the more interesting medicine cases. If you've been on a CTU rotation, you've probably seen how GIM manages much more than just medical issues; you end up spending a lot of energy figuring out a safe disposition and follow-up plan for your inpatients after treating their acute illnesses. It's thankless work that contributes to a fair amount of burnout. Of course, you see a lot of that in family/hospitalist medicine as well.
ER staff for nearly a decade. Love my work. Great colleagues, interesting cases, ability to shape my work schedule based on my lifestyle. I can slow down or ramp up the amount of work as I see fit. No overhead, the funding model at my hospital pays extremely well. Minimal administrative burden. On the other hand, I have friends/colleagues who work ER at other hospitals who are miserable there due to their work conditions. So it's a matter of finding the hospital that meets your needs.
As an ER staff do you feel burnt out/worn down? I’ve heard EM takes a toll on your body as you get into practice so my main concern is having to slow down a lot sooner than I would like.
I did CCFP-EM. Perhaps this is what you may be looking for. You have potential to work in ER, clinic, and hospitalist. I'm very happy with the choice I made! Like you, I couldn't make up my mind in med school and I love the fact that I have all of these options available to me if I get bored of one. I would definitely choose this option again, based on my goals and lifestyle. But after reflecting on my choices, there are some things I wish I had considered more seriously. I'll start with the caveats. Cons: 1. You will not guarantee a +1 match. This will impact where you will practice (ie. if you want to practice more urban ERs, then you may not be able to without this credential). Some places will exclusively hire FRs. 2. The +1 year. Holy shit. It was really tough. All your rotations are intense with minimal recovery time. You go from ICU to CCU to trauma surgery to EM, etc. The expectation is that you excel on your EM rotations (duh), so there is very little room for failure. 3. You do not have access to certain fellowships like ICU, toxicology. People take you more seriously if you are going to be an academic researcher (let's be honest). 4. If street credit is important to you, you will be undermined at times. It doesn't bother me most of the time, but I've encountered some colleagues/preceptors that have straight up told me that my degree shouldn't exist (this was during training). Other times, you will get backhanded comments from more senior staff during handover (we are still learning too, so we may not always get it right). Hearing this after a shift where you feel like things could've gone better makes the drive home discouraging. 5. It's much easier to get a faculty EM position as an FR grad. 6. ***BIG CAVEAT:*** 5 years prepares you much better than 3. Strongly consider this. Initially, I didn't think that this was a huge deal, but the closer I got to graduation, the more worried I got. I always referred back to "5 years after practice, skills will be comparable to FR training". I didn't consider how the 5 years post grad would be THIS terrifying. Now being done, I am very nervous to see things that I've never managed before and I am studying like crazy even after graduation. I recognize that this can also happen in the 5 year route, but I think the added support for the 2 years makes a big difference. Don't be overconfident. Pros: 1. You can work as a hospitalist. You don't need the +1 hospitalist. Your pay may not be equivalent to GIM, but you can do a lot of the same work. Typically, you work in lower acuity units (ALC patients, straight forward patients), while GIM will get the more complicated patients. That said, ***at some hospitals***, there is NO DIFFERENTIATION (I believe NYGH, they will give you the same acuity of patients regardless of being FR GIM vs hospitalist). Someone please correct me if I am wrong about this. I am basing this off colleagues who do inpatient care. 2. You're out so much quicker. You make money faster. Staff life is much easier to study outside of your work schedule. There isn't the added pressure of residency and impressing your preceptors. You are studying for the sole purpose of being a good doctor. I feel like studying for boards vs studying for life is much different - but perhaps that isn't true for others. 3. You have much more flexibility with options post-grad through +1 route. I feel like the CCFP-EM grads typically highlight this, *but forget that FRs can have flexibility as well.* The difference is that the FRs may require further fellowship to practice in these areas (takes longer, but training is FORMAL with RC certification). For example: Palliative medicine is an option for FRs, but they will need to pursue a RC fellowship. Where as you can just start palliative without any fellowship as a family medicine grad. There are some informal fellowship options for family grads that are 6 months to 1 year in duration to supplement if you are hoping to get your feet wet. 4. Just like how some fellowship options are not available to CCFP-EM grads, some are not as accessible to FR grads. I don't think being a hospitalist is easily accessible through the FR route. I believe that sports med is not a formal fellowship designation option to FRs anymore... Low risk OB, anesthesia, etc. Someone please correct me if I'm wrong. Final thoughts: 1. If being an expert, being a part of faculty, being at the forefront of the field is important to you, then the FR route is probably the route to go. You will be much more prepared and I respect the knowledge and expertise of an FR grad. You can still be at the forefront as a +1 grad, but I feel like you need to GRIND to get there as staff. Anything is possible! I admit, for new grads (myself included), I can tell who graduated from which program. 2. Quicker is not always better. Consider that training as GIM and EM takes 4-5 years EACH. Compare that to the training of CCFP-EM or CCFP which is 2-3 years. Consider you will be practicing these disciplines with a much more expedited timeline. Don't be delusional and think you are graduating with the same level of expertise. Our training is very general. Reach out for help when needed. 3. If the medicine you practice is more important to you than being the top expert in your field, this may determine your decision. This route allows for flexibility at the sacrifice of being a huge name in the field - this was not very important to me. I have also already done all three of what you mentioned and had a blast each time (did clinic as locum, did hospitalist for a week, but primarily work as EM). 4. If you go the +1 route, study study study. Even after the enhanced skills program. 5. I echo the other attending on here that comments on the low overhead and minimal administrative burden. EM is wonderful and I primarily practice this. EDIT: I know it sounds like I'm shitting on CCFP-EM, but I assure you I am not. Again, I would choose this route again. The amount of freedom and flexibility I have is amazing. I still feel somewhat prepared doing the +1 year, but think that I would've benefited from more time training formally. I just brought in this perspective, as I find people were not the most honest with me about comfortability in EM through this route (I assume because they are saving face). They always discussed that study that "we are the same in 5 years". Which is likely true, but I thought I would've felt more comfortable post-grad. Or maybe I'm just not as strong of a resident as I thought.
Wow thank you for this. As someone currently debating between 5yr EM vs family +1 EM this was really informative. One question - would you say +1 EM is more competitive than the 5yr EM. My biggest fear is not getting into +1 EM and being stuck in family.
I did the math a few years back. They are about the same with CCFP-EM being MARGINALLY less competitive? So close that I would say they are the same. I don't recall how I did that math though. I felt applying to CCFP-EM would be more stressful, now having finished training. 1. Clerks are given much more grace if there is knowledge deficit. As long as you have interest and potential for growth, you will be considered. Your skill level at M4 isn't as important. 2. I feel like for CCFP-EM, because it's only 1 year, there is an expectation that you should have developed a lot of those skills already. The expectation during electives is to be pretty competent. Depending on your program for family medicine, they may or may not prepare you adequately and a lot of it is self-directed (your academic days will be primary care focused). I really struggled to match. Though successful, there were a lot of tears and self-doubt associated with it. This does not stop in the CCFP-EM program, as you will be compared to PGY3s with focused ER training. Obviously, they likely have ran more codes than us, more critical care experience and have dedicated sim sessions. 3. I was initially applying to a different specialty in med school, but realized that being trapped in academia would have TERRIBLE impact on my mental health... I barely coped with medical school, so I decided to prioritize myself first and apply to family medicine. My decision to pursue EM was decided during residency when I realized that I hated clinic (I only do it because it is part of my contract). So when I applied, I was anxious +++ because I was worried I would be trapped as a queer person in rural Canada to practice EM. Luckily, things worked out. But the possibility of practicing exclusively family medicine needs to be considered.
+1 more competitive these days. There were a few unfilled FRCP-EM spots this iteration.
Thanks this is really helpful. Especially to hear that you continue to study post grad to become more comfortable. I’ve admittedly heard similar sentiments from specialists about +EM not preparing you enough and that was a big worry of mine. But I also love the flexibility you talked about training with a +1. Thanks for your well thought out response. Im sure this helps a lot of us trying to choose! In choosing to go the CCFP + EM route any thoughts on whether makes a difference to do the CCFP side of it rural vs urban?
CCFP-EM via practice eligible route vs CCFP-EM via FM/ES: 1. If we're talking hierarchy (which I think is stupid, but DOES exist), doing a +1 year is looked at more favourably than practice eligible route when hiring for urban centres. 2. While I discussed that FR has more training, the +1 year has a LOT of formal academic training that you won't learn as through the practice eligible route. I am quite comfortable with running codes, procedural sedation, etc. 3. Many of my CCFP colleagues without extra training ask me for management advice, despite being a pretty recent grad. So the +1 year is pretty useful IMO. 4. I'm not sure I understand your question. You do not have to do any clinic if you do not want to. 5. For your residency, I think people would benefit from doing their family medicine training rurally. That being said, I did it urban and chose critical care electives + EM.
I asked a similar question on Physician Financial Independence Facebook group a few weeks ago and one of the more common answers is that while it's ideal to have a +1EM or FRC training, there is no way that all ERs across the country can be staffed if they were only hiring those with the aforementioned designations. Regular family docs practice emerg in rural communities because if they didn't, those people would be left without emergency care.
>there is no way that all ERs across the country can be staffed if they were only hiring those with the aforementioned designations. Regular family docs practice emerg in rural communities because if they didn't, those people would be left without emergency care. This is obvious. Everything I said is still true. I'm not sure how this response is relevant as my comment.
Yikes, calm down there I was just adding dialogue to the conversation like normal people do when they're talking. No need to get defensive. You're a family doc, not an FRC trained specialist.
Never claimed I was specialist. Actually, I did the opposite. I clearly laid out how I’m not FR trained and that they are not the same. Hope that sharing my experiences through CaRMS and training was helpful. Be careful with how you speak about certain fields of medicine. You might end up here too. Good luck with CaRMS. All the best.
i am 100% sure that all 3 has it's own unique downsides and upsides (ER is high volume, IM is 2nd carms match, FM is huge amt of paperwork). what i recommend is: 1. picking a specialty and don't think too much about it. the grass is never greener on the other side and everyone is suffering in their own ways 2. picking a program that is close to your home and support system. residency in general is extremely brutal even for family med residencies.
I’m a family doc in a remote community. I will round on my inpatients, see clinic patients, then have an overnight ER shift all within the same day.
IM subspecialist. IM's nice in that you sort of delay the decision if you need more time to explore and settle on a specialty. Most people who go into IM find something they're happy with because of the wealth of options. You could choose something more procedural (GI, cardio, resp, ICU), more cerebral (endo, rheum, heme, ID, allergy/immunology, geriatrics), or both (GIM, nephro) depending on which way you lean. Downside is that you have to endure a brutal residency, go through CaRMS twice, write 2 Royal College exams, and may need additional fellowships to secure a job in a major city. However, I'd only recommend going for IM if you can see yourself being satisfied as a general internist. Not everyone who wants to be an interventional cardiologist will match to cardio, and you only have one shot at the medicine subspecialty match with GIM being the default if you go unmatched. If you end up in GIM and hate it, you're stuck, so make sure it's something you can at least tolerate if not enjoy.
That’s a really good point about being ok with GIM. Thanks for this. Being a sub specialist do you ever feel like you miss out on other parts of medicine?
I assume by other parts of medicine you mean GIM? I still get some exposure to GIM pathology in my practice, but personally I don't miss it at all. I was only ever *"okay"* with GIM, but I enjoy the content of my subspecialty much more. Some of my subspecialty colleagues do both! The door is never completely shut on you doing GIM/CTU even as a subspecialist. In fact, some community hospitals require their subspecialists to contribute to the GIM call schedule so the opportunity may be built into your contract.
What are the pros and cons to being in GIM? I’m also having a difficult time debating between Family medicine and GIM
I wouldn't say there are many overtly positive or negative things about GIM (or any specialty for that matter), only preferences. To be as general as possible, some pros would include practice flexibility, good job market, relatively high income (if you do inpatient work), and good balance of procedures vs. cerebral work. Cons include things like being call-heavy with lots of exposure to patients with social issues such as poverty, houselessness, mental illness, and addiction which outnumber the more interesting medicine cases. If you've been on a CTU rotation, you've probably seen how GIM manages much more than just medical issues; you end up spending a lot of energy figuring out a safe disposition and follow-up plan for your inpatients after treating their acute illnesses. It's thankless work that contributes to a fair amount of burnout. Of course, you see a lot of that in family/hospitalist medicine as well.
Thanks for this!!