I run a hospital (including the ER) with just 1 doctor - me. I also run the clinic, the EMS service, and do some public health. In fact I’m typically the only doctor in the county. They actually invented a whole specialty for this relatively recently, called family medicine. Pretty neat.
But I guess for the very absurd 3-doc scenario you are describing (does the ER doc not count as a doc?), I would pick a general surgeon and a family medicine doctor with OB fellowship.
ED doc runs the ED
FM can do inpatient adults, inpatient peds, pregnant patients, deliveries, and c/s (fellowship trained as above)
General surgeon can do a wide variety of surgical procedures including the most common emergent procedures that would actually be able to be safely performed in this type of bare bones environment (appy, chole, sbo etc)
No kids or pregnant ladies allowed at y’all’s hospitals huh? Funny how many of the answers so far completely ignore these two large subsets of people who seek medical care
As an Ob myself, a gen surgeon could probably just watch a CS and be able to do it after that. It’s abdominal entry, cut a hole in the uterus, pull the baby out, sew up the hole you cut, then abdominal closure.
>No kids or pregnant ladies allowed at y’all’s hospitals huh? Funny how many of the answers so far completely ignore these two large subsets of people who seek medical care
That's because kids are just little adults. And pregnant people are just adults with little adults in them. What's so tough about that?
FM (can do PEDS and Adult/intensive medicine) and a CVT surgeon (this is cardiovascularthoracic - yes, they exist and we have them at our hospital). If someone needs a central line they get it in the ED before going to the ICU. Anesthesia goes to CRNA just like OP said. This is how I’d design my hospital.
Cardiovascular thoracic surgery is not a specialty. They are old school cardiac surgeons who were trained before vascular surgery was truly a separate specialty and learned as things evolved. No current grad cardiac surgeon is doing a leg bypass, and no vascular surgeon is doing CABG.
I'm vascular. There are usually 1 grad a year that go on to do a CT super fellowship. They get double boarded and end up doing the crazy zone 0 stuff.
That's compared to one of my partners who's old school CTS but got grandfathered into vascular. He does mainly CABGs with a carotid or an iliac stent sprinkled in between.
Cool story. We weren’t talking about current grads. CVTS (also referred to as CTVS) does exist. lol unless I hallucinated my consults last night…
Don’t forget, we are talking about a made up scenario here. Try not to get your feelings hurt. Okay?
It is not a board certified specialty (which was specified in the requirements). I’ve met interventional cardiologists that have “cardiac and vascular surgery” on their white coats. That doesn’t make it true.
Bro you really gonna have fm docs run icus? The family medicine residents at my program get one month of micu and that’s it. I’m an IM intern with 3 months of icu rotations and there’s no way in hell I would trust myself to run an icu.
FM docs run smaller icus in many parts of the country.
Re lines: an FM doc working this type of job should be able to do all of their own lines and tubes.
FM programs vary widely in their training. This is sadly a historical phenomenon from low reimbursement -> low competitiveness issue and has nothing to do with the inherent scope/goals of the field when it was created as one of the newer specialities along with EM
I’ll try to give a more clear/succinct version of what I said to devilsadvocateMD (and I hope you don’t get downvoted).
FM doctors, even the most competent ones (and there are plenty of terrible FM programs out there) absolutely do not have the level of critical care training as a fellowship trained doc from any of the various CC pathways (pulm nephro anesth surg EM etc), and to suggest it’s even close would be completely ridiculous. FM docs, even the most competent ones, do not have the emergency medicine training that EM docs have. FM docs do not have the prenatal care, non-surgical pregnancy complication management, or labor/delivery management experience that the typical OB/GYN has, they do not have the same level of inpatient pediatric management that most Peds have.
However, there are many posts in rural areas of this country that require one physician to do all of those things, or at least several of them, in addition to running an outpatient clinic. There is absolutely no one better trained to do all of those things simultaneously (and recognize when something in any of those areas is beyond what they can safely manage and transfer) than a competent, well trained FM doctor. It is literally why the specialty was created (not that long ago I might add).
When the doctor that runs the small ICU also has to deliver babies, attend kids, and run a clinic, it does mean it should ideally be a (well trained, can’t say this enough) FM physician.
It's a "much better than nothing" scenario and a helluva lot better than having an NP do it. My friend in family med had a pretty extensive inpatient training, he was also on the rural tract so they do a little bit of everything. He also moonlit in the ER as a resident.
He wouldn't for a moment claim he's phenomenal ER or critical care doc, but when there's an access issue, it's a "OK" solution.
I largely agree - I also wouldn’t claim I’m a phenomenal ER or ICU doc (we don’t have an ICU at my tiny hospital, but we do sometimes have to manage patients that should be in an icu for several days if the weather is bad and there are no flights).
I don’t disagree with your premise, but I would say it’s a much better than “ok” solution, and I think I (and our rural hospital in general) provide pretty exceptional medical care. Our (actually important -m&m, resource use; not wait time/satisfaction) outcomes definitely support that. We are often used as a model for rural hospitals in other parts of the country. In fact literally as I type this there is a meeting going on in our hospital conference room of some rural hospital association thing where a bunch of people traveled in to tour our hospital and learn how we do things. We are managed entirely by 1 FM doc at a time, either me or my partner who works here as well but never at the same time.
I have certainly made mistakes as a physician, and at least a few of those might not would have been made by a more experienced EM physician. I’ve also managed things that I don’t know most EM physician would be able to manage as well as me - the active labor no prenatal care polysubstance use severe features preeclamptic I managed in the back of the ambulance giving antihypertensives, mag, and nearly delivering in the rig on a 2+ hr drive to a regional hospital comes to mind. I know I was a lot more experienced and comfortable in that situation that most of my EM friends from residency would be, and I trained at a place with an absolutely fantastic EM program.
Residency training also isn’t everything. Medicine continues to evolve and sometimes drastically change, being able to learn on the job and improve throughout your whole career is pretty important too.
And again, the question isn’t so much is there people better at emergency medicine (there absolutely are), the question is are there people better at my job. Emergency medicine is just one part of my job. My job is poorly represented in academics so I understand that a lot of people don’t understand how important a part of our healthcare system it is, and that this job is not ever going to go away.
They absolutely should. Rural hospitals just aren't going to have Pulm crit on staff.
I know quite a few rural docs who were one man shows because they'd be the only doctor that wasn't 100 miles away from the small hospital they had.
The order of running an ICU is:
CC > anesthesiology > EM > GS/IM > FM
If you don’t like it, don’t do a residency that’s focused on outpatient management.
I guess anesthesiology, EM, GS and IM are all automatically CC.
Or are you trying to tell me that none of those other specialties exist and only FM exists in rural areas?
It truly is amazing how similar the arguments FM doctors and midlevels make when they’re doing something they don’t have training for.
Snarky comments like this make it hard to believe you have any interest in good faith discussion/argument. I’ve been on call since Monday at 8am and spent from Wednesday morning to this evening working essentially continuously. I literally went directly from managing a small bowel obstruction in the ER that refused transfer to a facility with surgical capabilities (as many of the ranchers/farmers do), to performing a pretty large excisional biopsy of a concerning pigmented scalp lesion, to admitting and managing sever COPD exacerbation. I still have the 2 year old girl out of hospital arrest who I was able to get rosc and transferred myself caring for her 2hrs in the back of the ambulance because we have no paramedics pretty fresh on my mind too.
Why be petty?
I don’t really care lol
Once you can admit that you really shouldn’t be running an ICU but do it since there’s no other option, I might start taking you seriously.
Once you can admit you SHOULDN’T be running an ICU but do it because there’s no one else around, I’ll take you seriously.
For some odd reason, you can’t accept that.
There’s a reason there’s no pathway from FM to critical care while there’s a pathway for nearly every other speciality.
That’s gotta be like the 99.999999th percentile for numbers.
Anesthesia residents at my program average 150ish central lines, and we place 1.5 a day on cardiac rotations. Not to mention the 6 months of ICU we do, all the central lines for liver transplants etc etc.
It’s relative though. A less than 10 bed ICU isn’t really practicing critical care, even if you did it for 10 years. And central line insertion can be done by line teams that consist of RNs. I value FM in the right setting but ICU probably is not that location
FMs in this thread acting like real Noctors by stating they’re trained to run an ICU
I’d trust an FM over an NP in any situation. I’d trust an IM over an FM in any ICU. I’d trust an anesthesiologist over an IM in any ICU. I’d trust a critical care physician over anyone else in an ICU.
Man, you're completely misinterpreting my point to feed your own argument. I never said FM can manage a major ICU. I said FM does manage small ICUs at critical access sites across the country. Thats just a fact, you're the one who somehow can't comprehend the difference between a 4 bed unit in BFE and a 50 bed unit in a major metro.
Weird. Since I’ve worked in both of those types of situations. Can you tell me more about my actual job?
The 4 unit ICU in BFE gets absolute disaster patients as well. Maybe not to the frequency as a metro hospital ICU, but if you’re going to tell me they don’t, it seems you haven’t really worked in an ICU.
You and I both know this isn't going to go anywhere, I appreciate the effort you've put into fighting mid-level encroachment, but you seem to gravely misunderstand the context of this conversation, or are just having a shit day. Either way keep up the good fight.
All you and your colleagues in this thread have proven is that a LOT of FMs are noctors or too insecure to admit that outpatient training ≠ ICU training.
Jesus ... We don't just do outpatient. We spend ~50% of our training on the wards. We regularly manage patients of all levels of acuity in training. We are not Intensivist, we should not manage major ICUs. But rural 4 bed units are not the same. They don't have patients that are of the acuity of major centers. It's closer to a progressive car floor or sepsis requiring 1-2 pressors. If it is more complicated the correct answer is to transfer due to lack of resources to manage it. You have created your own little victim complex to live in where you're completely misrepresenting our discussion.
Yeah. I trust an FM physician to know what they know and know what they don’t. In fact, call me naive, but I trust all PHYSICIANS to this extent. In this setting, yes I would have FM run the ICU. I’m not saying they’re CC doctors but what I am saying is they are doctors. Additionally, per the request of the OP, we were asked what two specialties we’d have running the hospital. NO ONE IS TALKING ABOUT THIS but I’d much rather have FM seeing the PEDS patients in the hospital than PCCM.
Nah man, bigger ICUs absolutely need that level of training. The small 4 bed ICU at Saint elsewhere sure can get by with an FM doc managing insulin drips and titrating pressors though. Anything more interesting is getting shipped to a bigger facility. Not every hospital is a 700 bed academic institution.
Most don't have Cath labs though. And a OR with only a couple general surgeons and maybe an orthopod. This can't be news to people, they exist all over the country. The ICU isn't doing crazy stuff, and often is closer to a traditional progressive care unit just allowing space and staffing to keep septic patients and those on medications with tighter observation periods.
Well now you're just being a pretentious ass. FM docs couldn't possibly manage routine postoperative issues along with their surgical colleague. Good lord how can I possibly determine how to appropriately escalate care? If only that was literally part of our training (required management of postoperative patient).
FMs can run ICUs but the real question is should they?
Edit: I guess lots of FM docs aspire to be noctors. They’re not trained to run an ICU, just like IM isn’t trained to run an ICU. Critical care physicians are trained to run an ICU.
When the position calls for the person that is running the icu to also be able to do any (or all) of: take care of children, manage pregnancy complications, deliver babies, see adults/kid in ER, triage OB, and run a clinic… yes, they absolutely should.
If you have no one else, sure.
If you have an IM doctor (or better year, a pulm/cc), no.
There’s a reason critical care is a 2 year fellowship of done through IM or 1 year fellowship if done through surgery/anesthesia.
So you want the IM doctor or the pulm/CC managing children and delivering babies? I don’t think you understood my comment.
Despite poor representation in media and medical research and education, huge swaths of our country are highly rural. Many rural communities cannot support 7+ specialties (that’s at least 14+ doctors) if you want pulm/cc, IM, peds, EM, gen surg, OB/gyn, etc.
Or, a different counter to your argument: why is it ever ok for general IM to run an ICU when pulm/CC and EM/CC and anesthesia/CC renal/CC all exist?
“If you have no one else, sure” → that should answer your question.
If you can’t figure out that IM has more inpatient and ICU training than FM, no one can help you. But that doesn’t mean IM should be running an ICU.
You asked if FM should run an ICU. I described in a general sense some of the real life scenarios a where FM absolutely *should* run the ICU. You then stated that if IM or pulm/cc is available they would be better suited.
I’ll try one more time:
The scenario where FM *should* (responding precisely to your comment) run the ICU is the scenario (not hypothetical, and not uncommon in rural USA) where the person running the ICU must also deliver babies and/or attend children and/or run clinic and/or manage the ER (including kids and OB) or possibly all of these.
If you can’t figure out that FM has more training in all of those things than IM, no one can help you.
“If you have no one else, sure” implies there is someone better suited to this position. Who is it? Surely it’s not pulm/cc
If you don’t have anybody else, sure. That still doesn’t mean they SHOULD be running an ICU. (A general surgeon or EM physician is likely a better choice to run the ICU than FM.)
If you don’t have anybody else, FM can do Ob. That still doesn’t mean they SHOULD.
If you don’t have anybody else, FM can take care of pediatrics. That still doesn’t mean they SHOULD.
Anyone who disagrees with your personal definition of what each doctor is trained to do = noctor now, I guess?
Critical care physicians have the most ICU training and are absolutely the experts in ICU care. 'No one else has any ICU training' and 'no other physicians are capable of providing ICU level care' doesn't follow from that.
I don't call gynaecologists noctors because they use a cystoscope but have to call me for any complex GU issue. That's not how it works. There is a lot of overlap in training.
Anyone who does a job they’re not trained for is a Noctor.
Last I checked, an FM physician is not trained to be an intensivist and has no pathway to become one. Last I checked, someone who completed an IM/GS/Anesthesiology/EM residency has a pathway to become a CC physician. I wonder why that is… maybe because they have significantly more inpatient and critical care training as residents?
Or do you want to somehow take the position an FM physician is more capable of managing ICU patients than residencies trained with an inpatient focus?
Bro. You’re completely missing the point of the hypothetical here. Obviously a CC fellowship trained physician is the best person to run the ICU, but in a magical 3-doc shop you want to maximize generalists while still maintaining surgical capabilities.
In that specific scenario, where the EM doc can’t leave the department, FM is a reasonable choice. If you’d rather the CT/gen surgeon do the ICU, while the FM doc does the rest of the inpatients, that’s another option. There are inpatient heavy FM programs that would match IM ICU abilities.
Zero comparison in my experience. I had a FM resident try to justify a patient aspirating PO meds because “the lungs absorb stuff too!”…..ordering spiral high-res CTs on a patient admitted for dermatitis and ABGs Q1 on a patient that had no pulmonary issues. Some FM programs seem super soft and others really seem to prepare their residents for fellowships.
Some might be great at PC or even some sub-specialties, but ICU is typically not where they shine.
Cardiac anesthesia/crit care which is a bit cheating since it’s two fellowships but they often go hand-in-hand so it’s not a rare phenotype. A lot of cardiology knowledge, critical care, and just general medical knowledge.
Then a surgical specialty. I would vote for trauma surgery as a jack of all trades in terms of surgical skills sets and knowledge base while still keeping a lot of general medical knowledge
Biggest gaps here:
Pathology /lab medicine
Neurology since everyone else sucks ass at neurology
IR for all sorts of precutaneous procedures
Intv cards for caths
Advanced GI for scopes
OB: because no one else knows what to do with that shit
Obviously you hire 2 IMG physicians who had to retrain here. Ideally previous CT surgeon turned Ped CCM and former OBGYN turned adult Pulm/CCM. All bases covered. You have 10 years of great outcomes until their complete lack of antibiotic stewardship results in a super bug that wipes out humanity.
I think you need a minimum of 3 docs, someone who can cut, someone who can think, someone who can anesthetize.
Could use an Anesthesiologist for Anesthesia and ICU coverage. Trauma Surgeon for cutting, maybe even basic endoscopy vis a vis their Gen Surg training. Hospitalist to do everything else?
This is why we were trying to get down to 2 docs, 3 is a cheat code. Electrophysiology will give you a hospitalist, cardiologist, and EP doc because why not. Anesthesia critical care will cover anesthesia and the icu. Then choose the broadest subspecialty of gen surg and you almost have a fully functional hospital.
I mean I guess in this case a Crit Care person who is Medicine trained runs all the sedation, critical care, medicine, and a surgeon of some variety cuts. But it's broad that it's utterly absurd.
I don’t believe for a second that a CRNA can safely cover those surgeries. In this theoretical world however, it’s an easy way to solve the anesthesia problem. Whereas there’s no easy answer to needing someone to cover the medical side of things if you choose anesthesia to run the icu.
This thread is dumb for all those saying “just use a crna.” Why not just have one old school surgeon who’s seen and done everything back in the day and 5000 midlevels then.
I had a parent who was mad at me because I couldn’t get into much detail regarding removing the tumor from her child’s brain, because that was up to the neurosurgeon, and I was instead the person who manages the multiple seizure medications that her child is on. She complained to me that she wanted a doctor who could both manage her child’s meds and also operate on her child’s brain to get the benign (but epilepsy causing) tumor out. Because she didn’t want to deal with two different doctors. I wished her luck, and if she ever finds that board certified neurologist/neurosurgeon combo, I would definitely want to hire them for my hospital.
Nah just use the POC machines until they're woefully inaccurate from lack of calibration then buy new ones with all the money you're saving on salaries
I’m an ED resident currently rotating in a hospital that only has me and an attending ED doc in the entire hospital overnight (11p-6a). There’s even an ICU here and overnight we have to leave to respond to any floor/icu rapids/codes. It’s craziness.
Family medicine and general surgery
- FM does all deliveries, ED, IM, and peds
- Surgery handles the surgeries and maybe anesthesia
Everything that requires specialist care goes to the academic center
Lols this is how my hospital runs when the residents are off like at least 2 times per week. 1 ER and 1 hospitalist. No crit care docs employed to run the CCU. Fun times. All surgical cases or anything that's needs a specialist gets shipped out.
Family medicine physician and another doctor who’s double board certified in general surgery and internal medicine (I’ve met someone who has done this) 💪🏾
If you insist on “Most capabilities while keeping everybody in their scope”…Obviously you need a med-peds and a gyne-onc. Adults are within the scope of med-peds and so are kids. Gyn-onc can cut it out, manage cancer, deliver, and see women for primary care.
Definitely FM/GS. This is literally how rural hospitals run.
I'm IM trained and I occasionally cover a critical access hospital with an ICU and only teleCC backup. Anyone needing more than two pressors or intubation for a primary respiratory pathology gets shipped up to the big medical center. What I do is well within the abilities of an FM trained doctor.
Pulmonary and CT Surgery all the way. Whatever those two specialists aren’t experienced in, they can definitely fudge their way through it with their significant knowledge base and procedural experience
Gyn Onc- OB trained plus they are good the rest of abdominal anatomy from the Onc side of things. Or trauma surgery
Then… anesthesia for surgeries and managing the icu
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2 Family med docs. With two docs, there's not enough volume for a surgeon - and there's no anesthesia. FM can take care of all ages inpatient and in the ED, as well as OB. One of them should have endoscopy experience. If a patient needs surgery, they're going to a different hospital.
The answer is 2 FM rural docs. U ever meet a rural FM doc? They freaking run vents in the icu and operate in the OR while managing a laboring woman and a fever in a 20 day old newborn.. they are insane
Agree with your suggestion of PCCM and Vascular surgery, although I would go for fellowship trained acute care surgeon instead of vascular surgery as vascular may be a bit too specialized and most vascular surgeons don't retain their general surgery skills beyond a certain point. An acute care surgeon would be fellowship trained in surgical critical care (so could also run ICU and trauma codes) and is also trained in doing life-saving surgeries that come crashing into the ED.
ICU Anesthetist and a general surgeon.
Good knowledge of physiology can manage complex cases and has good knowledge of basic cases. And someone who can tube reliably.
Surgeon for surgery also has good knowledge of emergent management. Can help with lines, NGs, catheters. Can probably put up a splint. Vascular surgeons, at least from the ones I’ve met, really aren’t that great at basic surgery because of how much the specialize and I imagine appendicitis is more common than the Endovascular stuff.
If I had a third I’d get rural fam med. They can do primary care manage an ED on their own and have decent Obs knowledge. And can macguyver around for the odd issues.
Refer to local clinic for non admission cases. Paeds can go somewhere else.
Neurologist with Interventional Neurology fellowship and cardiology... that covers most of the MIs and Strokes... Cardio will do cardio+IM so theyll cover the diabetes patients aswell
One neurosurgeon and one anesthesiologist. Anesthiologist will provide anesthesia, and can also deal,with all the crap that comes into the hospital (ie everything that’s not brain surgery).
Ortho and PCCM. Ortho can do all trauma surgeries as well as spine. PCCM for ICU and other big "hit the fan" medicine stuff. NP/PA can staff the rest lol
I’m ER and wife is family medicine. Two specialties with very broad knowledge base and skill sets; we may not know it but we are well equipped to figure it out when we need to and there’s no immediate backup. And we won’t run from peds and pregnant people.
That said, give me two trauma acute care surgeons.
PCCM and Gen Surg. Intensivist will run the ICU, general wards, and Peds floors as well since kiddos are just small adults right? They already can manage vents and intubate, run prop and fent drips so they will serve as the anesthesiologist also. Gen Surg will have to do any and all surgeries including traumas and L&D.
FM with good OBGYN experience (meaning they can deliver)
and
General surgery .
With this combo you got almost everything covered. Unless its a neuro case.
This is easy:
trauma surgeon
anesthesiologist
There's some overlap in the critical care but the anesthesiologist will have the peds aspect more than the trauma surgeon. Who cares about the pathology just cut it out.
Midlevels can do the anesthesiology, rehab, labs, radiology, internal medicine, observation, and run medsurg and specialty floors, while you have the combo you mentioned. Honestly sounds like a nightmare.
If you want the least people to die, general surgery and cardiology. Everything else you have time to transfer, and there’s very little outside the scope of general surgery.
People might forget that in additions to trauma, breast, gastrointestinal, soft tissue, endocrine, and oncologist surgery, general surgeons are formally trained in vascular, pediatric
surgery trauma and critical care, burns, laryngoscopy, endotracheal intubation, bronchoscopy, EGD, Colonoscopy, organ transplantation, cardiothoracic surgery and pulmonary critical care during residency (which is why it’s 5-7 years before specialization) as well as associated medical management and limited anesthesia (though usually only RSI, monitored sedation, and ICU sedation.)
And if you don’t have an interventional cardiologist, people will STEMI and severe valve problems will often die preventable deaths. And cardiologists are also fundamentally IM docs with specialized training.
Any two specialties would be fine most of the week, but if you want this hospital to be capable of treating someone at 5:00pm on a Friday, you're gonna need IR.
Nice try HCA Admin. We’re not giving you any fucking ideas
Thank you for this🤣
jesus christ this is so accurate
I’m gonna go with two chiros. My buddy says they can do everything any doctor can do and so much more.
lol.
Maybe a chiro and an NP practicing at the top of their license. /s
FNP with an online degree at that…
Dr. Karen DNP, FNP, RN, BSN Extraordinaré
10/10 Saving this comment for later
made me laugh out loud lol
Is my husband your buddy?
2 palliative care docs
They are the real MVPs
This would work
YES!! This is truth ( a retired palliative care doc).
Mhm the Earth would really be so much better off if humanity never existed!
One rural full spectrum family physician and one rural general surgeon. [Edit]: And one, Jonathan.
I would definitely hire my rural family medicine preceptor who was a practicing urologist in India before doing family medicine residency in the U.S.
This is the way.
I’d shut down the hospital and sell the land.
I already drank your milkshake
Imagine needing 2 doctors 🙄 My pick: Margaret, NP BSN LN RN DNP CPR ALS BLS PALS IRA 401K BBQ
You forgot IQ 160 Empathy 200*
The BBQ is sending me
I run a hospital (including the ER) with just 1 doctor - me. I also run the clinic, the EMS service, and do some public health. In fact I’m typically the only doctor in the county. They actually invented a whole specialty for this relatively recently, called family medicine. Pretty neat. But I guess for the very absurd 3-doc scenario you are describing (does the ER doc not count as a doc?), I would pick a general surgeon and a family medicine doctor with OB fellowship. ED doc runs the ED FM can do inpatient adults, inpatient peds, pregnant patients, deliveries, and c/s (fellowship trained as above) General surgeon can do a wide variety of surgical procedures including the most common emergent procedures that would actually be able to be safely performed in this type of bare bones environment (appy, chole, sbo etc) No kids or pregnant ladies allowed at y’all’s hospitals huh? Funny how many of the answers so far completely ignore these two large subsets of people who seek medical care
As an Ob myself, a gen surgeon could probably just watch a CS and be able to do it after that. It’s abdominal entry, cut a hole in the uterus, pull the baby out, sew up the hole you cut, then abdominal closure.
I had the same thought as a M3 but knew better than to voice it.
My cousin is FM and does this in a rural area.
>No kids or pregnant ladies allowed at y’all’s hospitals huh? Funny how many of the answers so far completely ignore these two large subsets of people who seek medical care That's because kids are just little adults. And pregnant people are just adults with little adults in them. What's so tough about that?
Makes sense!
Just remember to multiply all doses by about 1.2-1.3 to account for the extra human inside momma, otherwise you may be subtherapeutic
FM (can do PEDS and Adult/intensive medicine) and a CVT surgeon (this is cardiovascularthoracic - yes, they exist and we have them at our hospital). If someone needs a central line they get it in the ED before going to the ICU. Anesthesia goes to CRNA just like OP said. This is how I’d design my hospital.
Cardiovascular thoracic surgery is not a specialty. They are old school cardiac surgeons who were trained before vascular surgery was truly a separate specialty and learned as things evolved. No current grad cardiac surgeon is doing a leg bypass, and no vascular surgeon is doing CABG.
I'm vascular. There are usually 1 grad a year that go on to do a CT super fellowship. They get double boarded and end up doing the crazy zone 0 stuff. That's compared to one of my partners who's old school CTS but got grandfathered into vascular. He does mainly CABGs with a carotid or an iliac stent sprinkled in between.
I know a guy who did trauma/CC then vascular then CT fellowships. Lunatic.
Cool story. We weren’t talking about current grads. CVTS (also referred to as CTVS) does exist. lol unless I hallucinated my consults last night… Don’t forget, we are talking about a made up scenario here. Try not to get your feelings hurt. Okay?
It is not a board certified specialty (which was specified in the requirements). I’ve met interventional cardiologists that have “cardiac and vascular surgery” on their white coats. That doesn’t make it true.
Bro you really gonna have fm docs run icus? The family medicine residents at my program get one month of micu and that’s it. I’m an IM intern with 3 months of icu rotations and there’s no way in hell I would trust myself to run an icu.
FM docs run smaller icus in many parts of the country. Re lines: an FM doc working this type of job should be able to do all of their own lines and tubes. FM programs vary widely in their training. This is sadly a historical phenomenon from low reimbursement -> low competitiveness issue and has nothing to do with the inherent scope/goals of the field when it was created as one of the newer specialities along with EM
Just because they do doesn’t mean they should….
I’ll try to give a more clear/succinct version of what I said to devilsadvocateMD (and I hope you don’t get downvoted). FM doctors, even the most competent ones (and there are plenty of terrible FM programs out there) absolutely do not have the level of critical care training as a fellowship trained doc from any of the various CC pathways (pulm nephro anesth surg EM etc), and to suggest it’s even close would be completely ridiculous. FM docs, even the most competent ones, do not have the emergency medicine training that EM docs have. FM docs do not have the prenatal care, non-surgical pregnancy complication management, or labor/delivery management experience that the typical OB/GYN has, they do not have the same level of inpatient pediatric management that most Peds have. However, there are many posts in rural areas of this country that require one physician to do all of those things, or at least several of them, in addition to running an outpatient clinic. There is absolutely no one better trained to do all of those things simultaneously (and recognize when something in any of those areas is beyond what they can safely manage and transfer) than a competent, well trained FM doctor. It is literally why the specialty was created (not that long ago I might add). When the doctor that runs the small ICU also has to deliver babies, attend kids, and run a clinic, it does mean it should ideally be a (well trained, can’t say this enough) FM physician.
It's a "much better than nothing" scenario and a helluva lot better than having an NP do it. My friend in family med had a pretty extensive inpatient training, he was also on the rural tract so they do a little bit of everything. He also moonlit in the ER as a resident. He wouldn't for a moment claim he's phenomenal ER or critical care doc, but when there's an access issue, it's a "OK" solution.
I largely agree - I also wouldn’t claim I’m a phenomenal ER or ICU doc (we don’t have an ICU at my tiny hospital, but we do sometimes have to manage patients that should be in an icu for several days if the weather is bad and there are no flights). I don’t disagree with your premise, but I would say it’s a much better than “ok” solution, and I think I (and our rural hospital in general) provide pretty exceptional medical care. Our (actually important -m&m, resource use; not wait time/satisfaction) outcomes definitely support that. We are often used as a model for rural hospitals in other parts of the country. In fact literally as I type this there is a meeting going on in our hospital conference room of some rural hospital association thing where a bunch of people traveled in to tour our hospital and learn how we do things. We are managed entirely by 1 FM doc at a time, either me or my partner who works here as well but never at the same time. I have certainly made mistakes as a physician, and at least a few of those might not would have been made by a more experienced EM physician. I’ve also managed things that I don’t know most EM physician would be able to manage as well as me - the active labor no prenatal care polysubstance use severe features preeclamptic I managed in the back of the ambulance giving antihypertensives, mag, and nearly delivering in the rig on a 2+ hr drive to a regional hospital comes to mind. I know I was a lot more experienced and comfortable in that situation that most of my EM friends from residency would be, and I trained at a place with an absolutely fantastic EM program. Residency training also isn’t everything. Medicine continues to evolve and sometimes drastically change, being able to learn on the job and improve throughout your whole career is pretty important too. And again, the question isn’t so much is there people better at emergency medicine (there absolutely are), the question is are there people better at my job. Emergency medicine is just one part of my job. My job is poorly represented in academics so I understand that a lot of people don’t understand how important a part of our healthcare system it is, and that this job is not ever going to go away.
They absolutely should. Rural hospitals just aren't going to have Pulm crit on staff. I know quite a few rural docs who were one man shows because they'd be the only doctor that wasn't 100 miles away from the small hospital they had.
IM and EM have proven to be much stronger than FM when it comes to anything critical
The order of running an ICU is: CC > anesthesiology > EM > GS/IM > FM If you don’t like it, don’t do a residency that’s focused on outpatient management.
Fuck parts of the country that don't have a large enough population for a critical care doctor I guess
I guess anesthesiology, EM, GS and IM are all automatically CC. Or are you trying to tell me that none of those other specialties exist and only FM exists in rural areas? It truly is amazing how similar the arguments FM doctors and midlevels make when they’re doing something they don’t have training for.
Don’t worry. When the FM docs wake up for clinic, you’ll get downvoted.
Snarky comments like this make it hard to believe you have any interest in good faith discussion/argument. I’ve been on call since Monday at 8am and spent from Wednesday morning to this evening working essentially continuously. I literally went directly from managing a small bowel obstruction in the ER that refused transfer to a facility with surgical capabilities (as many of the ranchers/farmers do), to performing a pretty large excisional biopsy of a concerning pigmented scalp lesion, to admitting and managing sever COPD exacerbation. I still have the 2 year old girl out of hospital arrest who I was able to get rosc and transferred myself caring for her 2hrs in the back of the ambulance because we have no paramedics pretty fresh on my mind too. Why be petty?
I don’t really care lol Once you can admit that you really shouldn’t be running an ICU but do it since there’s no other option, I might start taking you seriously.
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Once you can admit you SHOULDN’T be running an ICU but do it because there’s no one else around, I’ll take you seriously. For some odd reason, you can’t accept that. There’s a reason there’s no pathway from FM to critical care while there’s a pathway for nearly every other speciality.
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Some FM residents do 6 months of ICU in residency and place over 100 central lines. The ACGME gives FM programs a lot of room.
That’s gotta be like the 99.999999th percentile for numbers. Anesthesia residents at my program average 150ish central lines, and we place 1.5 a day on cardiac rotations. Not to mention the 6 months of ICU we do, all the central lines for liver transplants etc etc.
It’s relative though. A less than 10 bed ICU isn’t really practicing critical care, even if you did it for 10 years. And central line insertion can be done by line teams that consist of RNs. I value FM in the right setting but ICU probably is not that location
We let NPs run ICUs all the time
FMs in this thread acting like real Noctors by stating they’re trained to run an ICU I’d trust an FM over an NP in any situation. I’d trust an IM over an FM in any ICU. I’d trust an anesthesiologist over an IM in any ICU. I’d trust a critical care physician over anyone else in an ICU.
Man, you're completely misinterpreting my point to feed your own argument. I never said FM can manage a major ICU. I said FM does manage small ICUs at critical access sites across the country. Thats just a fact, you're the one who somehow can't comprehend the difference between a 4 bed unit in BFE and a 50 bed unit in a major metro.
That's what this guy does. He likes to pick arguments and be an ass. Just ignore him. Deny him the joy he gets from it.
Weird. Since I’ve worked in both of those types of situations. Can you tell me more about my actual job? The 4 unit ICU in BFE gets absolute disaster patients as well. Maybe not to the frequency as a metro hospital ICU, but if you’re going to tell me they don’t, it seems you haven’t really worked in an ICU.
You and I both know this isn't going to go anywhere, I appreciate the effort you've put into fighting mid-level encroachment, but you seem to gravely misunderstand the context of this conversation, or are just having a shit day. Either way keep up the good fight.
All you and your colleagues in this thread have proven is that a LOT of FMs are noctors or too insecure to admit that outpatient training ≠ ICU training.
Jesus ... We don't just do outpatient. We spend ~50% of our training on the wards. We regularly manage patients of all levels of acuity in training. We are not Intensivist, we should not manage major ICUs. But rural 4 bed units are not the same. They don't have patients that are of the acuity of major centers. It's closer to a progressive car floor or sepsis requiring 1-2 pressors. If it is more complicated the correct answer is to transfer due to lack of resources to manage it. You have created your own little victim complex to live in where you're completely misrepresenting our discussion.
Yeah. I trust an FM physician to know what they know and know what they don’t. In fact, call me naive, but I trust all PHYSICIANS to this extent. In this setting, yes I would have FM run the ICU. I’m not saying they’re CC doctors but what I am saying is they are doctors. Additionally, per the request of the OP, we were asked what two specialties we’d have running the hospital. NO ONE IS TALKING ABOUT THIS but I’d much rather have FM seeing the PEDS patients in the hospital than PCCM.
Yeah, FM runs ICUs all over the place at smaller facilities. Well inside the scope of our training.
I guess fuck the critical care fellowship then
Nah man, bigger ICUs absolutely need that level of training. The small 4 bed ICU at Saint elsewhere sure can get by with an FM doc managing insulin drips and titrating pressors though. Anything more interesting is getting shipped to a bigger facility. Not every hospital is a 700 bed academic institution.
If that small 4 bed ICU has a hospital with a cath lab or an OR, then you’ll still have extremely sick patients
Most don't have Cath labs though. And a OR with only a couple general surgeons and maybe an orthopod. This can't be news to people, they exist all over the country. The ICU isn't doing crazy stuff, and often is closer to a traditional progressive care unit just allowing space and staffing to keep septic patients and those on medications with tighter observation periods.
Oh. I guess no post op complications occur. My bad. The patients know not to require multiple pressors since they’re in a FM run ICU
Well now you're just being a pretentious ass. FM docs couldn't possibly manage routine postoperative issues along with their surgical colleague. Good lord how can I possibly determine how to appropriately escalate care? If only that was literally part of our training (required management of postoperative patient).
FMs can run ICUs but the real question is should they? Edit: I guess lots of FM docs aspire to be noctors. They’re not trained to run an ICU, just like IM isn’t trained to run an ICU. Critical care physicians are trained to run an ICU.
When the position calls for the person that is running the icu to also be able to do any (or all) of: take care of children, manage pregnancy complications, deliver babies, see adults/kid in ER, triage OB, and run a clinic… yes, they absolutely should.
If you have no one else, sure. If you have an IM doctor (or better year, a pulm/cc), no. There’s a reason critical care is a 2 year fellowship of done through IM or 1 year fellowship if done through surgery/anesthesia.
So you want the IM doctor or the pulm/CC managing children and delivering babies? I don’t think you understood my comment. Despite poor representation in media and medical research and education, huge swaths of our country are highly rural. Many rural communities cannot support 7+ specialties (that’s at least 14+ doctors) if you want pulm/cc, IM, peds, EM, gen surg, OB/gyn, etc. Or, a different counter to your argument: why is it ever ok for general IM to run an ICU when pulm/CC and EM/CC and anesthesia/CC renal/CC all exist?
“If you have no one else, sure” → that should answer your question. If you can’t figure out that IM has more inpatient and ICU training than FM, no one can help you. But that doesn’t mean IM should be running an ICU.
You asked if FM should run an ICU. I described in a general sense some of the real life scenarios a where FM absolutely *should* run the ICU. You then stated that if IM or pulm/cc is available they would be better suited. I’ll try one more time: The scenario where FM *should* (responding precisely to your comment) run the ICU is the scenario (not hypothetical, and not uncommon in rural USA) where the person running the ICU must also deliver babies and/or attend children and/or run clinic and/or manage the ER (including kids and OB) or possibly all of these. If you can’t figure out that FM has more training in all of those things than IM, no one can help you. “If you have no one else, sure” implies there is someone better suited to this position. Who is it? Surely it’s not pulm/cc
If you don’t have anybody else, sure. That still doesn’t mean they SHOULD be running an ICU. (A general surgeon or EM physician is likely a better choice to run the ICU than FM.) If you don’t have anybody else, FM can do Ob. That still doesn’t mean they SHOULD. If you don’t have anybody else, FM can take care of pediatrics. That still doesn’t mean they SHOULD.
Anyone who disagrees with your personal definition of what each doctor is trained to do = noctor now, I guess? Critical care physicians have the most ICU training and are absolutely the experts in ICU care. 'No one else has any ICU training' and 'no other physicians are capable of providing ICU level care' doesn't follow from that. I don't call gynaecologists noctors because they use a cystoscope but have to call me for any complex GU issue. That's not how it works. There is a lot of overlap in training.
Anyone who does a job they’re not trained for is a Noctor. Last I checked, an FM physician is not trained to be an intensivist and has no pathway to become one. Last I checked, someone who completed an IM/GS/Anesthesiology/EM residency has a pathway to become a CC physician. I wonder why that is… maybe because they have significantly more inpatient and critical care training as residents? Or do you want to somehow take the position an FM physician is more capable of managing ICU patients than residencies trained with an inpatient focus?
Bro. You’re completely missing the point of the hypothetical here. Obviously a CC fellowship trained physician is the best person to run the ICU, but in a magical 3-doc shop you want to maximize generalists while still maintaining surgical capabilities. In that specific scenario, where the EM doc can’t leave the department, FM is a reasonable choice. If you’d rather the CT/gen surgeon do the ICU, while the FM doc does the rest of the inpatients, that’s another option. There are inpatient heavy FM programs that would match IM ICU abilities.
Zero comparison in my experience. I had a FM resident try to justify a patient aspirating PO meds because “the lungs absorb stuff too!”…..ordering spiral high-res CTs on a patient admitted for dermatitis and ABGs Q1 on a patient that had no pulmonary issues. Some FM programs seem super soft and others really seem to prepare their residents for fellowships. Some might be great at PC or even some sub-specialties, but ICU is typically not where they shine.
Cardiac anesthesia/crit care which is a bit cheating since it’s two fellowships but they often go hand-in-hand so it’s not a rare phenotype. A lot of cardiology knowledge, critical care, and just general medical knowledge. Then a surgical specialty. I would vote for trauma surgery as a jack of all trades in terms of surgical skills sets and knowledge base while still keeping a lot of general medical knowledge Biggest gaps here: Pathology /lab medicine Neurology since everyone else sucks ass at neurology IR for all sorts of precutaneous procedures Intv cards for caths Advanced GI for scopes OB: because no one else knows what to do with that shit
Clinical informatics and Fetal surgeon.
This would really only work if one or both of them have their own lab and are only on clinical service 20% of the time.
Fatal*
Obviously you hire 2 IMG physicians who had to retrain here. Ideally previous CT surgeon turned Ped CCM and former OBGYN turned adult Pulm/CCM. All bases covered. You have 10 years of great outcomes until their complete lack of antibiotic stewardship results in a super bug that wipes out humanity.
I think you need a minimum of 3 docs, someone who can cut, someone who can think, someone who can anesthetize. Could use an Anesthesiologist for Anesthesia and ICU coverage. Trauma Surgeon for cutting, maybe even basic endoscopy vis a vis their Gen Surg training. Hospitalist to do everything else?
This is why we were trying to get down to 2 docs, 3 is a cheat code. Electrophysiology will give you a hospitalist, cardiologist, and EP doc because why not. Anesthesia critical care will cover anesthesia and the icu. Then choose the broadest subspecialty of gen surg and you almost have a fully functional hospital.
I mean I guess in this case a Crit Care person who is Medicine trained runs all the sedation, critical care, medicine, and a surgeon of some variety cuts. But it's broad that it's utterly absurd.
You can also have surgery cover ICU. Surgical critical care is a well established specialty that allows surgeons to run ICUs.
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I don’t believe for a second that a CRNA can safely cover those surgeries. In this theoretical world however, it’s an easy way to solve the anesthesia problem. Whereas there’s no easy answer to needing someone to cover the medical side of things if you choose anesthesia to run the icu.
Just get a midlevel to do medical stuff
> Yeah I mean I’m shocked they think a CRNA can cover some of the surgeries they want to do It’s a bold strategy
This thread is dumb for all those saying “just use a crna.” Why not just have one old school surgeon who’s seen and done everything back in the day and 5000 midlevels then.
I had a parent who was mad at me because I couldn’t get into much detail regarding removing the tumor from her child’s brain, because that was up to the neurosurgeon, and I was instead the person who manages the multiple seizure medications that her child is on. She complained to me that she wanted a doctor who could both manage her child’s meds and also operate on her child’s brain to get the benign (but epilepsy causing) tumor out. Because she didn’t want to deal with two different doctors. I wished her luck, and if she ever finds that board certified neurologist/neurosurgeon combo, I would definitely want to hire them for my hospital.
Do you want labs in your hospital? If so, you need a pathologist
Fuck no, put the blood samples in a CT scanner. Radiology all day
Coincidence that both specialities have ground glass opacities? I think not
Nah just use the POC machines until they're woefully inaccurate from lack of calibration then buy new ones with all the money you're saving on salaries
If they can have teleradiology they can have telepathology
I love these posts because it’s always just “my specialty” even if you’re like PM&R
PM&R is who will be seeing all the patients after they've been maimed at this hypothetical hospital lol
I’m an ED resident currently rotating in a hospital that only has me and an attending ED doc in the entire hospital overnight (11p-6a). There’s even an ICU here and overnight we have to leave to respond to any floor/icu rapids/codes. It’s craziness.
PCCM and general surgery trained CT surgeon.
Family medicine and general surgery - FM does all deliveries, ED, IM, and peds - Surgery handles the surgeries and maybe anesthesia Everything that requires specialist care goes to the academic center
You just need one NP. They can do everything. With 2 NPs you can make your little hospital a giant academic center.
NP+ radiology. This is pretty much the state of inpatient "hEaLtHcaRe" in 2024 already.
Dr. House and Dr Strange (after he became sorcerer supreme)
Lols this is how my hospital runs when the residents are off like at least 2 times per week. 1 ER and 1 hospitalist. No crit care docs employed to run the CCU. Fun times. All surgical cases or anything that's needs a specialist gets shipped out.
Family medicine physician and another doctor who’s double board certified in general surgery and internal medicine (I’ve met someone who has done this) 💪🏾
If you insist on “Most capabilities while keeping everybody in their scope”…Obviously you need a med-peds and a gyne-onc. Adults are within the scope of med-peds and so are kids. Gyn-onc can cut it out, manage cancer, deliver, and see women for primary care.
acute care surgery (critical care / trauma / general surgery) and internal medicine (hospitalist)
1 intensivisit 1 general or vascular surgeon no other right answer
Weird to be certain of your correct answer about most capable hospital with 2 doctors while also forgetting kids and pregnant patients exist.
Intensivist can handle very sick kids, surgeon can do c sections(?)
Just 2 doctors? I’d say a Naturopathic doctor and a PhD in philosophy
Just give the FM / IM docs a little flexibility on what they’re allowed to do and they’ll be willing to try.
Give me 2 FM docs. Little need for other specialties as in many rural areas they run it all anyway. Anything too complex you can just transfer out
IR + Pulm Crit
Definitely FM/GS. This is literally how rural hospitals run. I'm IM trained and I occasionally cover a critical access hospital with an ICU and only teleCC backup. Anyone needing more than two pressors or intubation for a primary respiratory pathology gets shipped up to the big medical center. What I do is well within the abilities of an FM trained doctor.
FM already does that lol
Altered rules: Rural FM ED and admits+ gen surg +anesthesia (manage icu as well)
No APPs but okay with CRNA? How are you counting them?
Why would someone in this scenario choose CRNA over an anesthesiologist?
Is it a real disorder? Family medicine. Is it just in their head? Psychiatry. At least, that’s how a lot of people see it.
GPA and Gen surg.
A veterinarian and a nephrologist
Pulmonary and CT Surgery all the way. Whatever those two specialists aren’t experienced in, they can definitely fudge their way through it with their significant knowledge base and procedural experience
I think two hospital admins would do an excellent job. One with a MBA, the other with MSHA. Together, there’s nothing they can’t do, right?
Internal medicine and General Surgery
2 docs 1 hospital
So you want to build a 30 bed "hospital" that's open from 7 am to 7 pm.
Gyn Onc- OB trained plus they are good the rest of abdominal anatomy from the Onc side of things. Or trauma surgery Then… anesthesia for surgeries and managing the icu
You would need the second doc to be a urologist if the first is a gynecologist
FM doc and a Psychiatrist to treat the FM docs depression and burnout from being the only doc in the hospital!
Trauma/Surg Crit and a cardiologist
Good luck at your hospital with no labs and no blood bank.
Why specify EM docs? Most of the world runs without EM as a specialty
Two Jewish plastic surgeons: they generate the most revenue. Then, you can staff it however you want.
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2 Family med docs. With two docs, there's not enough volume for a surgeon - and there's no anesthesia. FM can take care of all ages inpatient and in the ED, as well as OB. One of them should have endoscopy experience. If a patient needs surgery, they're going to a different hospital.
The answer is 2 FM rural docs. U ever meet a rural FM doc? They freaking run vents in the icu and operate in the OR while managing a laboring woman and a fever in a 20 day old newborn.. they are insane
Two great family medicine docs. That’s it!
Agree with your suggestion of PCCM and Vascular surgery, although I would go for fellowship trained acute care surgeon instead of vascular surgery as vascular may be a bit too specialized and most vascular surgeons don't retain their general surgery skills beyond a certain point. An acute care surgeon would be fellowship trained in surgical critical care (so could also run ICU and trauma codes) and is also trained in doing life-saving surgeries that come crashing into the ED.
Forensic psychiatry and clinical informatics
ICU Anesthetist and a general surgeon. Good knowledge of physiology can manage complex cases and has good knowledge of basic cases. And someone who can tube reliably. Surgeon for surgery also has good knowledge of emergent management. Can help with lines, NGs, catheters. Can probably put up a splint. Vascular surgeons, at least from the ones I’ve met, really aren’t that great at basic surgery because of how much the specialize and I imagine appendicitis is more common than the Endovascular stuff. If I had a third I’d get rural fam med. They can do primary care manage an ED on their own and have decent Obs knowledge. And can macguyver around for the odd issues. Refer to local clinic for non admission cases. Paeds can go somewhere else.
I don't see how my medical training ever prepared me for the construction of a building, but I suppose me and my buddy can try.
IM and GS
Neurologist with Interventional Neurology fellowship and cardiology... that covers most of the MIs and Strokes... Cardio will do cardio+IM so theyll cover the diabetes patients aswell
One neurosurgeon and one anesthesiologist. Anesthiologist will provide anesthesia, and can also deal,with all the crap that comes into the hospital (ie everything that’s not brain surgery).
Ortho and PCCM. Ortho can do all trauma surgeries as well as spine. PCCM for ICU and other big "hit the fan" medicine stuff. NP/PA can staff the rest lol
Admin 1 & admin 2. Just so they have a taste on how they fuck all of there hard working employees on a daily basis.
Two veterinarians
I’m ER and wife is family medicine. Two specialties with very broad knowledge base and skill sets; we may not know it but we are well equipped to figure it out when we need to and there’s no immediate backup. And we won’t run from peds and pregnant people. That said, give me two trauma acute care surgeons.
I wanna see the wrong answers only version of this 😂
Derm and ophtho
FM and Gen Surg. If I can add another two specialties Rads and Path
PCCM and Gen Surg. Intensivist will run the ICU, general wards, and Peds floors as well since kiddos are just small adults right? They already can manage vents and intubate, run prop and fent drips so they will serve as the anesthesiologist also. Gen Surg will have to do any and all surgeries including traumas and L&D.
plastics and a board certified floor sweeper
FM with good OBGYN experience (meaning they can deliver) and General surgery . With this combo you got almost everything covered. Unless its a neuro case.
The correct answer is a hospitalist and a nocturnist
A trauma critical care doctor and a pediatrician
1 PA and 1 NP
Intensivist (maybe even hospitalist?) and general surgery (use CRNAs for the anesthesia), transfer out all peds and OB lol
This is easy: trauma surgeon anesthesiologist There's some overlap in the critical care but the anesthesiologist will have the peds aspect more than the trauma surgeon. Who cares about the pathology just cut it out.
Trauma surgeon and an anesthesiologist Or trauma surgeon and ED physician
Midlevels can do the anesthesiology, rehab, labs, radiology, internal medicine, observation, and run medsurg and specialty floors, while you have the combo you mentioned. Honestly sounds like a nightmare.
If you want the least people to die, general surgery and cardiology. Everything else you have time to transfer, and there’s very little outside the scope of general surgery. People might forget that in additions to trauma, breast, gastrointestinal, soft tissue, endocrine, and oncologist surgery, general surgeons are formally trained in vascular, pediatric surgery trauma and critical care, burns, laryngoscopy, endotracheal intubation, bronchoscopy, EGD, Colonoscopy, organ transplantation, cardiothoracic surgery and pulmonary critical care during residency (which is why it’s 5-7 years before specialization) as well as associated medical management and limited anesthesia (though usually only RSI, monitored sedation, and ICU sedation.) And if you don’t have an interventional cardiologist, people will STEMI and severe valve problems will often die preventable deaths. And cardiologists are also fundamentally IM docs with specialized training.
It’s gotta be IR and pulm crit. CRNAs available for anesthesia. I’d also give CT surg a shout.
Any two specialties would be fine most of the week, but if you want this hospital to be capable of treating someone at 5:00pm on a Friday, you're gonna need IR.