EM Outside the ER: Alternative Pathways in Emergency Medicine

Shilpi Ganguly, MS-IV, University of Miami Miller School of Medicine
EMRA MSC Southeast Regional Coordinator 2022-2023

Matthew Lyons, OMS-IV, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
EMRA MSC Southeast Regional Representative I 2022-2023

Daniel Aloise, MS-IV, Florida International University Herbert Wertheim College of Medicine
EMRA MSC Southeast Regional Representative II 2022-2023

Kyle Cohen, NRP, OMS-III, Alabama College of Osteopathic Medicine
EMRA MSC Southcentral Regional Representative 2022-2023

Emergency medicine is a unique field that offers providers the opportunity to serve as a safety net to a diverse population with a wide range of pathologies. EM physicians are tasked with being prepared to oversee cases ranging from mild primary care-type complaints to acute life-threatening injuries and disease. While the scope of the emergency department is vast, many may not realize just how many opportunities training in emergency medicine can truly offer. Looking beyond the ED, there exist a multitude of career paths for EM doctors to pursue. These opportunities may serve as unique career routes, or as an adjunct to shifts in the ED. We delve here into some of these emergency medicine subspecialities and non-traditional pathways. 

Sports Medicine

Following residency, EM physicians have the option of attending a 1 year primary care sports medicine fellowship. While not unique to emergency medicine (family medicine and internal medicine residents can also apply to sports medicine), sports medicine offers a unique opportunity for those of us that enjoy orthopedics, but may not have fallen in love with the operating room. Many emergency medicine physicians that complete a sports medicine fellowship continue to practice regularly in the ED, while protecting a day or two weekly for their sports medicine clinic. Clinic patients may present with a wide range of musculoskeletal injuries and require procedures such as steroid injections, nerve blocks, PRP and stem cell injections. By having an additional outlet for work outside the emergency department, EM doctors often say this helps to keep their work life fresh and prevent burnout. In addition to clinic days, EM physicians trained in sports medicine can also find their way onto the playing field, serving as a team physician. Offering a different path to serving as a team doctor from orthopedic surgeon counterparts, these physicians are uniquely trained to address any acute injury that may occur in the game, especially noteworthy, as most injuries sustained are non-operative, such as sprains and concussions. If you have a love for emergency medicine and a passion for athletics, this may be the career path for you.

Telemedicine

Telemedicine, which first emerged in the United States in the 1960’s, has recently become a rapidly growing field in the wake of the pandemic. Though many may perceive emergency medicine as a specialty that must be performed in-person, there is increasing utility for telemedicine in EM. Telemedicine has been hailed as a tool that can help bridge the gaps in healthcare across both our country and the world. With this technology a provider in South Africa can instantaneously transmit live video feed to another provider in Miami, FL. Telemedicine has proven beneficial for managing non-life-threatening pathologies that may have otherwise been sent to the “fast-track” section of the ED and taken up unnecessary resources and time. Rather than force patients who may not have the means to obtain transportation or the ability to spend the time and money to sit and wait hours in the emergency department, a large number of ED visits may be assisted by telemedicine technology. Currently, there exist two telemedicine fellowships, which may be 1 or 2 years in length, however, expect this number to grow in the near future!

Ultrasound

Though bedside ultrasonography is used routinely as a standard part of emergency medicine practice, ultrasound is a fellowship option that stands to directly improve physician capabilities in the ED and improve patient outcomes. In addition to improving ultrasonography skills inside the emergency room, this fellowship also offers additional opportunities outside the ED, such as serving as an ultrasound director or working to teach ultrasound to practioners around the world. As a non-invasive and inexpensive source of imaging, ultrasound is an appealing option in the global health arena, and additional training to master and teach ultrasound skills can be of great use to the underserved, especially in low income countries.

Emergency Medical Services

A fellowship in Emergency Medical Services (EMS) takes 1 year to complete after residency. The fellowship involves learning the clinical and administrative tasks needed to become a leader in the prehospital environment. Fellows often have a dedicated EMS vehicle to respond to emergency calls alongside EMTs and paramedics. Many fellowships also offer a flight program that the fellow can be involved in as well. After receiving board certification, there are a wide range of career opportunities for EMS physicians. Examples include medical director for EMS agencies, fire departments, and law enforcement agencies, as well as administrative positions for state and federal postings.

Disaster Medicine

In 2021 there were 16 Disaster Medicine fellowship programs across the country. Some of the fellowships are a 2-year combined track with an EMS fellowship while others are 1-year singular Disaster Medicine fellowships. The career opportunities after completing a fellowship are very broad. Some graduates work on a local level assisting with emergency planning for their local hospital, while others focus on global response efforts. There are also many government and military positions available to Disaster Medicine trained physicians. Without a doubt, these physicians are well trained to lead teams for disaster relief work no matter the scale or environment.

Addiction Medicine

The field of Addiction Medicine is rapidly growing and currently includes 86 ACGME accredited fellowship programs. One can complete a fellowship after completing one of several different residencies, including internal medicine, family medicine, emergency medicine, or pediatrics. The fellowship takes 1-2 years to complete. A career after an Addiction Medicine fellowship is dependent on the specific skills and training selected during training. Many fellowship-trained physicians work in inpatient or outpatient addiction treatment centers. Addiction medicine is a growing need in emergency departments as many hospitals are working to develop addiction treatment protocols rooted in the ED.

Pediatric Emergency Medicine

Pediatric Emergency Medicine (PEM) is an ACGME-accredited subspecialty that can be accessed by one of two ways and currently has 70 fellowships available. One pathway is for board certified EM physicians completing a 2 or 3 year fellowship in PEM. Alternatively, a board certified pediatrician can complete a 3 year EM fellowship. Additionally, the American Board of Pediatrics has approved 4 programs to conduct a 5 year combined residency program through a special agreement with the American Board of Emergency Medicine (ABEM). The end result is the same with a board certification in PEM and having a career in the pediatrics ED. Of note, for the EM physician completing the pediatrics fellowship, opportunities outside the ED in pediatrics may be somewhat limited.

Simulation

The use of simulation has greatly increased in medical education over recent years and the field of emergency medicine has recognized the need for formalized fellowship training. The length of a medical education simulation fellowship is between 1 and 3 years depending on the program and depth of study. Fellows have the opportunity to work with a variety of simulators, ranging from low-fidelity task trainers to high-fidelity simulators in full scale simulations. Additionally, fellows work with members from various disciplines, specialties, and levels of training including EMT students, nurses, radiology techs, respiratory therapists, and other physicians. Some programs offer an opportunity to obtain a certification through the Society for Simulation in Healthcare (SSH) as a Certified Healthcare Simulation Educator (CHSE) or Certified Healthcare Simulation Operation Specialist (CHSOS). After completing a fellowship in simulation, careers often look like a combination of education inside and outside of the ED, in addition to clinical responsibilities in the ED.

Pain Medicine

The field of pain medicine, or pain management, has been a growing field since its inception as part of anesthesiology in the 1980s. In 2014, the American Board of Medical Specialties (ABMS) approved EM physicians to enter into board certified fellowship in pain medicine. Currently there are around 100 programs with most of them being 1 year in duration. With this being an opportunity to be board certified in both EM and pain medicine, the choice is yours as to where you want to practice. Some choose to work in both the ED and pain clinic, while others stay within one specialty. Pain medicine is a procedure heavy specialty consisting of joint injections, spinal anesthesia, regional anesthesia, neuro-ablative procedures, and image-guided spinal interventions.

Aerospace Medicine

The field of aerospace medicine is one that is exciting and has rapidly expanded over the past decade. With a big push to make space a part of the normal human experience, there exists a growing need for physicians who specialize in ensuring the health and safety of its participants. While the field sits under the board for preventive medicine, it is open to all those who have completed a primary residency in emergency medicine. This field offers a multitude of exciting opportunities both in public and private sectors such as NASA or SpaceX. Working in aerospace medicine offers physicians the opportunity to trailblaze in the world of space travel, working on research, operations, and supporting astronauts. There are two accredited civilian programs and three accredited military programs. Of note, there are additionally two non-accredited space medicine fellowships that have recently emerged for those who have trained in emergency medicine only.

The above are just a few of the numerous fellowship opportunities available after training in emergency medicine. While it is impossible to cover them all, below is a (somewhat) comprehensive list of opportunities available for those who have successfully completed a residency in emergency medicine, recognizing that this list is forever growing. There is no limit to where and how a physician can make an impact after completing a residency in emergency medicine.

ABEM Subspecialties

• Addiction Medicine
• Anesthesiology Critical Care Medicine
• Clinical Informatics
• Emergency Medical Services
• Hospice and Palliative Medicine
• Internal Medicine - Critical Care Medicine
• Medical Toxicology
• Neurocritical Care
• Pain Medicine
• Pediatric EM
• Sports Medicine
• Surgical Critical Care
• Undersea and Hyperbaric Medicine

Other Board Certifications

• Disaster Medicine - American Board of Physician Specialties
• Informatics - American Board of Preventive Medicine

Non-Subspecialty Fellowships

• Administration/ED Operations/Patient Safety & Quality Improvement Fellowships
• Aerospace Medicine
• Cardiovascular Emergencies
• Forensic EM
• Geriatric EM
• Health Policy
• Injury Prevention
• International EM(Global EM)
• Medical Education
• Observation Medicine
• Occupational and Environmental Health
• Population Health and Social EM
• Research
• Resuscitation
• Simulations
• Tactical Medicine
• Telemedicine
• Ultrasound
• Wilderness Medicine
• Women’s Health

More Resources: EMRA Fellowship Guide: Opportunities for Emergency Medicine, 2nd Ed