The EM Mentoring Thread

Graylin · Apr 8, 2007

Welcome! I'm an Emergency Medicine Physician. I have and continue to participate in interviews/rankings/etc and work closely with residency development issues.

The EM forum is now open!

Questions for Residents, Physicians, and other Professional Mentors

1. What do you enjoy most about your specialty?
Emergency Medicine is a fast paced field that touches almost all specialties. I love the pace, the diversity and the team work that happens in the ED. Patients come in and you never know what they will have. Shift work is great as well. Its a nice lifestyle as well.

2. Is there anything you dislike about your specialty?
Shift work has many good things but it does mean that you work a varied scedule, including nights.

3. How many years of post-graduate training does your specialty require?
EM is a little odd in that there are 3 year programs, 4 year programs and a few 3 year programs that also require an extra one year internship. In essence, it is 3 or 4 years depending on where you apply.

4. What is a typical schedule like for your specialty? Are the hours/shifts flexible?
There is no typical scedule in EM. You work shifts (anywhere from 8-12 depending on where you go). Most attendings work about 35 hours a week.

5. Where do you see your specialty going in five years?
EM is not going anywhere. Its a growing field with plenty of job security.

Graylin · Apr 9, 2007

Hello everyone. As there is some overlap I am going to try and answser all of the proposed questions in one post. (keep in mind there are no absolute answers to this. These are my opinions based on my own personal experience).

I'll start with the easiest.

Why I love EM:

EM is a great field. Most people love it, who have done residency in EM. (go check out the EM forum and search 'burn-out', its addressed extensively) I have yet to come across people who advise 'don't do it' (this might be because I am in a highly competitive city and in academics). Like *all* fields of medicine, you must like what you are doing and realize no field is perfect.

What I love about it? My patients are undifferentiated... They have not come to me with partial work ups. I am starting from scratch and that appeals to me. I was also one of those people who liked something about every rotation but nothing enough to want to do that field exclusive of all others. EM is great for that. I get to do OB/gyn, ortho, medicine, cards, ID, ICU, peds, derm, fp, trauma, anesthesia, etc. I like the pace. Its often fast paced and I like to have several patients running at one time. I like the lifestyle- the fact taht my pager is buried in a drawer somewhere. I like shift work as it allows me to spend time with my family and do many other things. I can leave for a month and it has little effect on my 'patients'. The downsides? I do have to work some nights, some holidays. You don't 'know your patients for life' but for me, this wasn't as big of a deal. (and you do get 'regulars' trust me!).

Regarding what your own institution is like: you have to look at your EM profile: are they EM residency trained? in general, non EM trained EMP's often work more on the consultant end. However, in my institution, this is definitely not the case. We don't consult until we are pretty much done with the work up (ie appy's get called once we have diagnosed it and are ready to go to the OR; Ectopics are consulted once we have verified that there is no IUP on u/s etc; traumas are run by us, etc etc). If you feel you aren't getting a good feel of EM from your school, try looking at another institution, one with residents.

Regarding DO applicants
My program treats them pretty much the same.... However, not all programs do. some are DO friendly, others are not. Look in the EM forum, there are a number of DO's there and they have addressed this the past couple of years. (search DO applicants)

Regarding application issues for residency

There are no set answers for this. Numbers don't answer everything. But they also don't hurt. So you want to do well in your basics and get good evals in your third year. Strong LOR's. You want to show your interest in EM: student EM group, EMRA, etc. Research doesn't hurt but you should only do it if you are interested in it. Cultivate, to some degree, your non-medical interests.

WorkinEM · Apr 12, 2007

Ladyfingers said:
This may be a silly question, but are there any good organizations to join with regards to EM? I an incoming first year as well.

What about good EM journals or sites?

Not silly at all. EM is actually more complicated on this front than other specialties because there are several organizations and some of them disagree with each other on their core principles.

ACEP (the American College of Emergency Physicians) and its junior organization EMRA (the Emergency Medicine Residents Association) form the largest EM advocacy body. By joining EMRA you are de facto in ACEP. They discount dues for students. By being in ACEP you get Annals of Emergency Medicine which is one of the top journals in the field. You will also be able to attend all of the ACEP conferences and events.
http://www.acep.org

AAEM (the American Academy of Emergency Medicine) was formed around the belief that the corporate practice of EM (a practice set up where the docs work for a corporation that holds the contract with the hospital rather than contracting directly with the hospital) is ruining Emergency Medicine. It tends to be more concerned with practice structure issues than ACEP. It also believes that ACEP's leadership is biased toward corporate medicine, a claim that may be valid. AAEM discounts student memberships as well and you get the Journal of Emergency Medicine.
http://www.aaem.org

SAEM (the Society of Academic Emergency Medicine) is a body dedicated to emergency medical research. It is a very important organization for the academic faculty you will encounter as a student and a resident. Knowing what's going on in SAEM would help you to converse intelligently with these docs. Its journal is Academic Emergency Medicine.
http://www.saem.org

Graylin · Apr 13, 2007

abc56 said:
hello there fellow EM fans! I am a 3rd year med student looking to apply for a residency in EM because i think its the coolest/best specialty ever.

today i spoke with our dean, who sort of made me feel bad for wanting to stay on the east coast (either boston or new york) saying the best programs are out west (california, colorado)

i am really bummed because there is no way i will be happy living that far away from my friends and family (all in boston and new york) and had my heart set on living in new york if possible.

i guess my question is, what are some good programs in new york? where do i start looking (i know i'll get a feel when i interview) but i just need a little confidence booster after what she said to me today maybe i misinterpreted her, i dont know. she did make a point about how east coast programs are newer, and maybe thats why she thinks they're not as good, i dont know

The first step I would take is to meander down to the EM forum and search. There is a sticky on residency review. You can also search for 'best residency' (don't make a post, you might get McFattied). You can also search for residency reviews on www.scutwork.com

In essence, what you will get is that there are no 'best residencies' in EM. The RRC keeps a tight reign on programs. If you want to be in NYC or the east coast, then these are goign to be the best programs for you.

Regarding your dean, my initial guess is going to be that she is not in EM. Some of the oldest (and first) residency programs started in NYC. There are lots of new programs across the country. In NYC and the east coast, there is a mix of old and new. The programs in the east coast are excellent. If that is where you want to be, then go for it. There are great programs all across the country and what you have to do is figure out where is going to be a good fit for you.

Graylin · Apr 13, 2007

Doctor~Detroit said:
in terms of which med school to attend, would any of the following schools confer a distinct advantage over the others for matching in em in nyc and/or matching to a good program?: albert einstein, nyu, u chicago, u pitt. or would they all serve me the same?

thanks!

They will all serve you well. Naturally, doing a rotation at the program you want/like the most will be best because they will have a 'first hand' look at you. This can be a double edged sword but for most people it works out.

What people don't realize is that (in NYC) pretty much ANY rotation at ANY program will work well. The PD's all know each other because its a very very small community. They have done residencies together, worked together, etc.

The MOST IMPORTANT thing to remember is that what serves you best is the quality of your work and your attitude when you are rotating. Not the name of th institution. A mediocre LOR is a mediocre LOR. A great LOR is a great LOR>

WorkinEM · Apr 14, 2007

dsh said:
How does getting a job work post-residency? If I want to work in an (I'm assuming) competitive area like Southern California, should I try to match there?

How does getting a job work? Well assuming you have determined what type of job you want (academic vs. community, urban vs. rural, where you want to be geographically) you should start by asking your attendings if they know anyone in that market. You can also ask your PD if there are any grads from your program working in the market. That will give you a place to start. You can also cold call ERs in the area and ask for the directors to call you back so you can ask about jobs. This can be a little intimidating but can get you good info and has little down side. You can also talk to head hunters (people who find docs to fill jobs and get paid to do so) about the market. Finally you can talk to any staffing corporations that might have contracts in your market (for example EmCare, EPMG, etc.)

A note about headhunters: Be careful. They are paid to get you to sign on the bottom line. This is not the match and they don't care if you are a good "fit." Keep in mind when talking to headhunters that groups don't have to pay headhunters to fill the really attractive, sought after jobs.

If you want to work in SoCal. The simple answer is yes. You should try to match there if you know you want to work there. Most people wind up working near where they did residency. That being said lots of people don't settle where they trained. If you are sure of where you want to work try to train near there but if you don't you're not locked out forever.

One thing about job hunting as a doc. Again this isn't the match. It's not designed to be fair. In fact it's not even trying to be fair. It's going to be about who you know and how you interview.

Graylin · Apr 14, 2007

nev said:
Hi Dr. Graylin,
Thanks for volunteering. I have two questions for you.
1) I'm just curious if ER physicians are able to choose their hours and shifts (mornings only or afternoons only)
2) I noticed that in one of your responses, you said that you were involved in fields like ICU and Anesthesia. Could you tell me what you would be performing in these fields.

Thank you
Nev

nev-

1- EM is somewhat flexible in the sense that we tend to work less hours clinically than most fields. You often don't have a 'fixed' scedule early in your career. In general, you can't pick 'mornings only' or 'afternoon's only'. Because of the variations in practices : group, academic, contract, large corporation, etc, there are variations in scedules. Some people work nights (3 nights a week usually with a larger salary differential). Other people work 'days' which usually involves one or two nights a month and a variety of other shifts. Its kind of one of those things that's hard to explain until you spend some time in the ED. IN essence, its shift work. Many people like this, as there is no 'call' and your shifts are 'fixed'...... This has been awnsered more extensively in the EM forum. You might want to check there as well.

2- In the ER, we touch on all fields. Many patients are critically ill and thus require ICU management. The ED is the start of critical care. Septic patients, respiratory distress, toxidromes, etc are all initially managed in the ED. Now with many ICU's overflowing, these patients 'board' in ED's, so the EM doctor does much of the managing. Hence why there are now EM Critical Care fellowships. We do a lot of ICU patient management in the ED.

For gas, we tube LOTS of people. All emergently and using Rapid Sequence Itubation. We don't do the micro-pharm that gas people do, and our airways are much more stressful because we don't rely on the elective/semi-elective nature of the OR. Our patients are almost never npo, and not intubating is not an option.

Graylin

WorkinEM · Apr 16, 2007

Chulito said:
Graylin, WorkinEM, thanks in advance for your advice. I'm wondering about the differences between academic and non-academic EM.

1) Does an EMP in a university ED have to engage in research, or are there physicians who practice medicine and teach med students and residents, but who leave the research to others?

There are academic departments that have "clinical tracks" that are specifically designed to attract faculty who want to teach but don't want to live under the publish or perish system. These tracks tend to demand more shifts than the research positions, which seems fair. Some though limit the clinical staff when it comes to advancement and leadership positions which doesn't seem fair.

Chulito said:
2) How essential is it to engage in research as a medical student if you plan to apply for EM residency programs? Does the answer to this question depend on whether your #1 choice is a county-hospital program, a Johns Hopkins program or a program like EM/IM dual resideny at UCLA?

It helps. The more exclusive the program you want the more you need the little helper things on your app like research.

Chulito said:
3) What is the difference in potential pay between non-academic EM and academic EM?

The academics usually make a little less. 10-25% less seems to be the norm. Bear in mind that they usually have good benefitsm, often have less hours, get to take sabbaticals and so on. I firmly believe that no one should leave the academic vs. private practice up to the money aspect. The money is not different enough while the practice environments are very different.

Chulito said:
4) Do you think that the additional grounding in medicine provided by a dual EM/IM program would be worth the extra two years of residency for someone who is not interested in practicing at a university?

No. I don't think it has to do with going academic. I think it has to do with do you ever want to practice internal medicine. If you do then go for it. If you just want it as a stripe on your sleeve to get an academic EM job I'd skip it. There are other fellowships that will help you more if your interest is academic EM like Peds EM and Tox.

WorkinEM · Apr 16, 2007

Chulito said:
Thanks, WorkinEM. Good to know. I should have posed one other question regarding research while in medical school. Would an "unorthodox" project that ends in a publication, say with a professor of medical anthropology or a professor of public health, be as valuable in distinguishing a residency applicant as bench and clinical research are? I actually already have in mind a particular project of great personal interest dealing with cultural competency within med-school curricula, and a particular professor who is anxious to work with me; but I'm nervous that this kind of scholarship will simply not take the place of more traditional research in the minds of residency directors.

Good question. Your safest bet would be to do EM related research. That said I think that a project you are really excited about and interested in will serve you well in EM residency interviews. That excitement will likely come across and that type of enthusiasm will look good. You also need to keep in mind that EM is made up of pretty eclectic people and many will appreciate some diversity in your academic background. There are also getting to be more and more public health types (MPH and just interested) in EM. I say if you have a unique opportunity to do a project that excites you go for it.

WorkinEM · Apr 17, 2007

CarolinaGirl said:
Hi Graylin,

As a RN/FNP who used to work in the ICU I am a little familiar with shift work. What I wanted to know was how many shifts does an EM doc generally work? I know as a nurse 3-4 12's a week was full time. Is this the same for doctors or do you work more 12 hour shifts? My second question is do you work more 8hr or 12hr shifts? I realize this may be hospital dependent....

Thanks for your help in answering all of our quesitons

Most full time EPs work ~120 to 160 hours a month. There are lots of docs who work less for family reasons, etc. and make less money. There are also lots of EPs who work more (I know some who work 180-200/ mo) because they need the money or they work like that for 2 months and then take a month off. In my group the requirement to be considered full time is at least 120/ month and most average in the 140s.

The length of shift you work is very group/site dependent. In my group there are 8s, 8.5s, 9s, 10s and one 11.5 hr shift. These are at different times of day and at different hospitals. We set up the coverage to maintain adaquate staffing at that particular ED. Many groups work 12s and many work 8s.

As a rule that fits with the national averages expect to work 140 to 150 hours per month broken up into what ever shift system the group has, eg. 12 12s, 15 10s, 18 8s, 75 2s and so on

.

WorkinEM · Apr 17, 2007

Slinkeyooo

I noticed you did post over on the EM board about DO EM residencies. I also noticed it met with mixed results.

Just a note about the EM board. Any mention of the "best" EM residencies always generates flames for several reasons. It's been beaten to death and it assumes that if there are the "best" residencies there are also the worst. EM, possible more than any other specialty, has pretty good training across the board. Anyway, that's why your post was answered the way it was.

About your question, the main reason the DO residencies are distributed the way they are is that they tended to be near strong osteopathic schools. They are absent or scarce from many large metro areas because they were shut out for many years.

I don't know about expansion plans. You might try posting on the EM board with a question like "Does anyone know of any planned new DO programs?" or similar. A direct, limited scope question like that tends to get better responses.

WorkinEM · Apr 18, 2007

IMGfrom Sydney said:
Hi, and thanks to all the EM physicians providing advice. Just wondering if you would mind giving me your take on my situation (will try to be brief)

I will be applying to EM residencies as an IMG. Am a US citizen studying in Sydney (reputable program), have 3+ EM research years (work experience) at one of the better west coast EM programs, 20ish publications (2/3 of these are abstracts) mostly in EM, disaster medicine experience. I havent yet taken USMLE step I, but will do so the end of this year.

I've obtained 4 week EM electives at UC Davis and OHSU and have maintained my former professional contacts who have been very supportive of me.

Obviously applying as an IMG makes it more difficult for me, but am hoping a good USMLE score and my previous work/research experience will help. Additionally, working my butt off and doing well in my visiting electives and subsequently obtaining good letters of recommendation from those places will be a priority.

I made a choice to study in Sydney - was wait-listed/accepted at a US program - and trying to convince PDs of this might be a challenge.

Any suggestions??

Thanks

I would keep doing what you are doing. UCD has an Australian EP on faculty. You might ask the coordinator there if you can talk to her. She would be able to shed additional light on the situation.

WorkinEM · Apr 19, 2007

mtn0417 said:
I told my interviewer that I was interested in EM. I mean, I like high stress situations and am calm in them. I enjoy quick problem solving. I like the idea of no being limited to either diagnosing a patient or treating them. Furthermore, I'd like to have free time for my other hobbies.

However, after I told my interviewer I was interested in EM, which is all I said, he responded. "Oh so you want to work 1 day and have 3 days off" and then he changed subject. I mean, its not like I'm trying to be greedy and in it for the money. That kind of rattled me.

I assume this was a med school interview. There are a lot of people out there who don't like Emergency Physicians. We call them at 2am with emergencies. We ride them to actually do the right thing for patients. They perceive us as having an easy lifestyle. Med school interviews are often conducted by PhDs who have even less knowledge of EPs although they often have less animosity.

Here's what I'd say about your interviewer. You had the bad luck of encountering someone with an axe to grind against EM. To keep this in perspective you could just as easily have run into someone who hates surgeons, radiologists, people from Oregon, guys who wear loafers and so on. I would not try to hide your interests at interviews. You should convey that you have an open mind and that while you are interested you know that many people change their minds during med school and that you are open to that. If the interviewer is being less than professional about EM or whatever just emphasize that you are open to all specialties and are looking forward to the experience you'll gain as a med student. If they throw out a barb and change the subject let them and you stay professional.

aVR · Apr 19, 2007

I've been asked to help out with some of the DO EM questions since I'm at an osteopathic EM residency. I'll see what I can do.

slinkeyooo said:
Hello, Im going to be an oms1 this year and Im interested in emergency medicine. I know its a little early and things always change but its never too early to start thinking about the future... My question is that Ive noticed that theres about 37 osteopathic emergency medicine residencies however, there seems to be only single programs in large metropolitan areas and states such as in California and Chicagoland compared to mutlitple programs in rural areas why is this?

As someone else mentioned earlier, the DO programs tend to be affiliated with and located near DO schools, hence a large # of programs in Michigan, Ohio, New Jersey, and Pennsylvania. California isn't exactly a hotbed of osteopathic residencies in general, even though there are 2 DO schools. I'm not sure how many of the residencies are actually in truly rural areas, although some are in smaller cities.

How often are residency locations opened up? And whats the likelyhood of more er residencies opening up in larger more metropolitan areas?

I've heard that there are a couple of new residencies in the works, but I don't know the specifics.

Graylin · Apr 20, 2007

QuikClot said:
Hello Graylin, thank you for taking the time to answer our questions.

I have a question that is part professional, part personal interest. I'm an MS-1 and a paramedic who still works part-time. My question relates to the report given on ambulance patients with the transfer of care. Sometimes we speak to a doctor, often to a nurse, but there is a lot of variablity in terms of the receiving caregiver's affect. Sometimes they are clearly paying attention, sometimes they ignore you and your care and begin talking to the patient, and sometimes it's hard to tell what they're thinking.

So my question is, what is your attitude towards that report? I know what you mean about starting from scratch -- it's one of the things I love about EMS and EM -- but it reminded me of a question I've been wanting to ask someone "on the inside." What do you think, what are you taught, what is your experience with these reports? I ask both to guide me in presenting at the ER and to start thinking about hearing these reports as a resident. Thanks again.

Great questions. Traumas and notifications can be very crazy. The major pitfall and frustration is 'to many cooks in the kitchen'. We have very strict roles of who is allow to speak that we implimented about a year ago, to help streamline this (keeping the paramedics from having to give report to a nurse, md, resident etc over and over). So, now, we clearly id who is the senior resident adn all communication goes through him/her. as an attending, if EMS tries to give me report, I direct them to please speak to the senior resident. this streamlines it and makes it easy for every one to hear and important details not to get lost.

Field reports are very important. Nothing frustrates me more when a sick patient comes in (but not a 'notification') and EMS is no where to be found. But it happens and we move on..

Graylin · Apr 20, 2007

chumbojumbo said:
Hey Graylin,

Quick question. I applied to EM this year, but unfortunately did not match and was not able to scramble into a position. Not wanting to do anything but EM, I am now facing sitting out a year. My question is, what can I do this year to give myself a better shot at next year's match? Should I just try to get into any program and switch out, or should I do research, or something else...I am lost.

Thanks,

CJ

this was a very hard year in the match and I empathize with you. It is difficult to give specific direction on what to do, as each case is specific. however, the first thing I would do is speak with your EM advisor to see if you can sort out what your 'weaknesses' or 'areas of possible improvement' might be and focus on those. The other thing to look at is try and figure out if you applied appropriately. I believe that everyone should have a three tiered application process: a few 'dream' programs ('outta your league'), a good chunk of 'appropriate competitiveness' programs and a few 'fall backs'....

Transferring is tough. You can try adn scramble into a transitional but I wouldn't run into any program and then try to transfer... it makes things difficult etc.

I hope that helps!

Graylin · Apr 20, 2007

Chulito said:
Graylin, WorkinEM, thanks in advance for your advice. I'm wondering about the differences between academic and non-academic EM.

1) Does an EMP in a university ED have to engage in research, or are there physicians who practice medicine and teach med students and residents, but who leave the research to others??

As WorkinEM said, many places have clinical tracts... It is important however, if you want one of these positions to have a strong CV coming out of residencies, evidence that you like to teach, work with others, etc. We have plenty of EMP's in our academic institution who do not have research on thier agenda at all. However, almost all of them have some area of specialty: ems, disaster, teaching, trauma, cqi, etc etc.

2) How essential is it to engage in research as a medical student if you plan to apply for EM residency programs? Does the answer to this question depend on whether your #1 choice is a county-hospital program, a Johns Hopkins program or a program like EM/IM dual resideny at UCLA??

Again, doesn't hurt but only do it if you love it. If you don't, it shows. Instead, spend some time doing something EM related that you do love. It will show when you talk about it.

3) What is the difference in potential pay between non-academic EM and academic EM?

ditto WorkinEM

4) Do you think that the additional grounding in medicine provided by a dual EM/IM program would be worth the extra two years of residency for someone who is not interested in practicing at a university?

Depends on why you are doing it. most people end up doing one or the other.

beyond all hope · Apr 21, 2007

I am also an academic EM doc in NYC.

I think it's great that there are forums where students can reach out to those of us who've been through the process. I'm a recent residency grad and one of my goals is to make the process of training more humane to med students and residents.

Any questions please look through the FAQs and search the archives first, then feel free to PM me.

Graylin · Apr 22, 2007

BMW19 said:
We certainly appreciate you guys helping us future EM docs2B with advice. My Q's in no particular order:

1) We are being scared to death in school about how bad liability is in the field now. One attorney even came to our school to lecture us!! Supposedly EM is second only to OB/GN in the # of lawsuits. Since there is no continuity of care and no chance to establish rapport with the pt's. Do EM docs find this to be a big issue, or just part of the job?

I don't really find this to be a big issue. Its part of medicine in general. rapport can still be established even though you don't have continuity. If you let fear of lawsuits drive which field you go into, you will end up not happy in your job. Risk management, good practices, etc can reduce your chance of lawsuits. It is also important to dissect the #'s: BCEM (EM residency trained) vs non-EM. There are still tons of ED's that are staffed by non-EM people.

2) How do you view the dual programs IM/EM, FM/EM just more years or more options for the future?

I am not sure I really have an opinion one way or the other. I, personally, wonder about the utility. The IM/EM people I know, end up practicing one or the other. There is a complete myth that you can 'switch' 20 years down teh road. (do a search on burn out in the EM forum. its adressed extensively). That said, they are out there. I guess you just have to decide if its right for you. No one is going to say you suck as an EP because you are double boarded..... I would rather (and did) spend the extra years doing a fellowship in an EM related field but, I love EM.

3) 3 Vs. 4 year programs again, just another year or valuable extra training?

Depends on who you talk to. people at 4 year programs are going to tell you 4 is best. People at 3's are going to tell you 3. This has also been adressed alot in the EM forum. Try a search there. You can also look at both sides of the argument at www.emra.org. They have some info posted up about it. In essence, its a personal decision. I went three year.

4) For a 3rd year EM rotation would one get more out of rotating at a hospital with lots of residents (maybe benefit of messing up in front of residents) or one with very few residents (maybe more focused attention from attendings)

You are expected to make mistakes as a third year MS. I would recommend working with an attending. You will get good teaching, more procedures and also will develop a relationship with someone who can write you a LOR. That said, if you have no idea what a true ER looks like (one with residents) it doesn't hurt. Sometimes the private/communities can give you a more biased look at EM.

Thanks in advance for any wisdom you can give us...

BMW-

Your welcome! Hope that helps

WorkinEM · Apr 22, 2007

Emergency! said:
Hi -

For family reasons, I ended up taking a couple of months off this year (2nd year). The original plan was that I would start 3rd year rotations one rotation late, and then make up my two months 4th year by not taking all of my 3 months of vacation time. Initially, that seemed very reasonable. Then, I started hearing about how competitive this year's match was and wondering about how much my application would be hurt by being unable to do any EM rotations until September of Med4.

I have the opportunity to do a dual degree program next year (instead of Med3) that would then allow me to start Med3 rotations next July and put me back on track for the clinical years. I am really interested in the dual degree program, but a main reason for wanting to do the program is because I would rather spend a year doing something useful than end up not matching and having to reapply. (Or end up matching at a program lower down on my list).

Am I overblowing the impact of having a late application? There are other reasons that I am leaning toward the dual degree, but the above is probably the main one.

You would not be the first person to start interviews with only one EM block. You could try to assemble some additional thing like research and so on to augment your app. This is all far enough away that you have time to create some extras. Find an EM mentor at your school to help you.

Now, if you really want the extra degree go for it. It won't hurt you and it sounds like you are interested in it. But don't do it just to fill time.

WorkinEM · Apr 26, 2007

swoop said:
I am starting at a med school in the fall that does not have an accredited EM residency program. What steps might be wise to take in med school if I think EM is for me? as many away rotations as possible?

You should seek out on of the EM attendings at your school to be your mentor. You should see if your school has an EM interest group and join it if they do. If not think of starting one. Join EMRA or AAEM (see post above). Far and away the most important thing is to try to find an EM mentor. You can do this several ways. You can go down to the ED and ask who ever is on if there are any EPs who would be willing to help you out (explain your interest, etc.). You can find out who oversees the student rotations in your ED and contact that person about coat tailing and mentors. It probably won't be the first time its come up. You can talk to your faculty advisor and see if they can suggest any inroads. Good luck?

Graylin · Apr 26, 2007

WorkinEM said:
You should seek out on of the EM attendings at your school to be your mentor. You should see if your school has an EM interest group and join it if they do. If not think of starting one. Join EMRA or AAEM (see post above). Far and away the most important thing is to try to find an EM mentor. You can do this several ways. You can go down to the ED and ask who ever is on if there are any EPs who would be willing to help you out (explain your interest, etc.). You can find out who oversees the student rotations in your ED and contact that person about coat tailing and mentors. It probably won't be the first time its come up. You can talk to your faculty advisor and see if they can suggest any inroads. Good luck?

I also went to a school that did not have an EM residency. However, this does not condemn you to not being around EM academic individuals. Nor does it mean you can't find a way to EM. (I wasn't even thinking about EM until the end of my third year). I second what WorkinEm said: get an EM mentor! You will want to find some attending EM's in your home institution and work on developing a mentoring relationship. I would also recommend joining EMRA. There is also a virtual EM mentor from SAEM, designed specifically for individuals like yourself. Even in med schools where there are no residencies, there is still often an EM interest group. Try and get involved. Stay involved on the board here as well, in the EM forum. Lots of great advice and friendly relationships.

Best of luck!

Dr. Dukes · Apr 30, 2007

WorkinEM said:
There are academic departments that have "clinical tracks" that are specifically designed to attract faculty who want to teach but don't want to live under the publish or perish system. These tracks tend to demand more shifts than the research positions, which seems fair. Some though limit the clinical staff when it comes to advancement and leadership positions which doesn't seem fair.

How do the clinical tracks work? It is my understanding that "research tracks" have pretty obvious benchmarks (X papers and a reputation gets you Associate Prof, Y papers gets you full Prof...). How does it work for clinical tracks? Do you have to be involved in residency education or EMS or something, or do you get credit for simply (not simply) being a good doc?

Thanks for all your great answers!

Graylin · Apr 30, 2007

maximilliane said:
Hello! I have been thinking about whether to do Emergency Medicine or do Surgery and a fellowship in Trauma. I was in South Africa last summer and I loved the ER. I've had friends tell me that as a EP you don't get to do the big trauma.
I read the post concerning the girl who is attending Australien med school and well have a question concerning IMG's since I'm one too studying in Germany. I know that it will be difficult to match and I just want to increase my chances as much as possible. I've done away rotations in South Africa, Egypt and one at the US Army Hospital here. I am going to do 4 months of clerkship in South Africa next year and then hopefully 4 in the US.
I'm grateful for any and all advice!

I am not really sure what your question is. Are you uncertain about deciding between ER and trauma surgery?

I would search the EM forum. It has been adressed rather extensively as its not an uncommon dilemna. Surgery adn EM are very different. Tehre are overlaps.

In terms of doing away rotations, that is a great idea. If you do well on your step exams, do well on your rotations, get solid LOR's, you may have a harder time but not an impossible one.

Graylin · Apr 30, 2007

Micah6:8 said:
I will be an MSI this fall. I am entering as a non-trad, currently a physician assistant. I have worked in emergency medicine and FP. I am really interested in PEDS ED. My question is, which is the best route, Ed residency and then peds ed fellowship or peds residency and then fellowship? Thanks.

In general, most peple will say that it is better to do EM and then a peds fellowship. There are two reasons: time- its two years of fellowship if you come out from adult em program.

two- pay. When you work as an adult-peds EM person, you can negotiate part of your salary at an adult pay, which tends to be slightly higher than peds EM pay.

You have to ask yourself as well though, do you only want to work peds or do you want the option to also work in the adult ED.

Graylin · Apr 30, 2007

lanakai said:
Hi Graylin,

Thanks for offering advise. My husband and I are in a little bit of bind and we are trying to gather as much advice as possible.

Here is our situation: I'm a pretty middle of the pack, good board scores, third year UCLA med student applying to EM.

My husband is starting medical school in the fall of 2007 either at UCSF or at Mt. Sinai. We are from SF and would love to live there again eventually and they have great financial aid and housing. But the problem with him going to UCSF, is that there is at most 4 EM residencies within commutable range for me to apply to. And it seems a little insane for me to apply to only 4 residencies (especially because they are some of the most competative residencies) if I actually want to get a residency at all.

On the other hand, if he goes to Mt. Sinai, there are about 16 commutable EM residency programs for me (many of which according to my EM advisor are of average quality). My husband and I thought it might be fun to live in NYC temporarily, but it is going to be much more expensive and more difficult to return to SF.

Do you have any advice?

Thanks!

I am not sure why you think it might be harder to move back. In reality, both are about as equally expensive. California is incredibly difficult to match into. You are definately in a difficult position. I can tell you that I would probably go for more programs. Many in NYC have subsidized housing. One of my close friends has done residency in NYC and is moving to the bay area.

The problem with staying in california, is that ou might end up having to wait a year and re-enter the match or scramble and end up seperate.

I can't really tell you what is best. There really are no gaurantees in the match.

NYC is no more expensive than the bay area.

WorkinEM · May 1, 2007

Wackie said:
Can I ask a business question?

Some of the EM docs have PA's in the ER. I was curious as to how that works. Does the PA earn a percentage of what they bill and the doc gets the rest?

We use PAs. Our PAs get flat salary and the supervising docs get the patient billing. Other places do it differently to incentivise the PAs to see more patients. Our program has every patient get seen by the supervisory doc at some point in their ED stay. Other places don't but then you can only bill for the PA visit which is about 70% of a doc visit.

Groups change what they do based on their volume, staffing and payor mix.

WorkinEM · May 1, 2007

EMT2ER-DOC said:
Good morning,

I have been interested in EM for a long time. I have a couple of questions:

1) I have been an EMT for 15 years, is this an asset or should I forget what I have been taught to do and have a clean slate when looking into treating patients during my EM rotation?

2) Being a nonTraditional student (33 y/o) is it wise to go into EM or would it be better to go into FP?

3) Is it true that the hospital pays for your malpractice insurance?

4) How many years of intership and residency is it before you can become an attending?

5) Is the burnout rate that high?

thanks

1. No don't forget everything, build on it. I found that my EMT background allowed me to be better at codes and sick patients early on as I didn't get overwhelmed. You will be able to revert to ABC and keep your head.
2. Go into either but don't make the decision based on the burnout issue. If you think you'll be happy in EM you will be less likely to burnout. Much of the old burnout mantra was based on non EM trained docs who wound up in EM for reasons other than love of the field.
3. Usually. There are situations where you pay your own but the majority of jobs pay your med mal. Those that don't pay you more cash to buy your own. If they didn't they wouldn't be competitive.
4. You can do 3 or 4 years of post grad training to do EM. The majority of EM residencies are 3 year.
5. See above and see the voluminous threads about burnout on the EM forum.

WorkinEM · May 1, 2007

DoctorPardi said:
I've certainly heard a lot of good things about EM in this thread, but what are the worst parts of your job? Is there anything you hate, is it specific to EM?

Also before EM what other specialties did you consider and what specifically about EM made you choose it over them?

Good Questions. I hate the useless workups on people who are not really sick, the people who use the ER as primary care, the people who use the ER because their outpatient workup wasn't happening fast enough and the adversarial and defensive environment that the med mal crisis puts us in.

Some things that are more EP specific that don't get talked about too much are the PMD dumps when the patient is HMO, uninsured or if they're just complicated and in clinic at 4:30pm.

One thing that has had almost no time on SDN is the fact that as "contract docs" EPs are frequently dumped on by their hospitals. Gas, Rads and Path sometimes get caught in this as well. The issue is that "contract docs" are granted access to the ED (or OR and OR specimens) by the hospital. The hospitals can threaten the contract if you're not willing to do what they want. Contract docs don't have patient panels and can't threaten to refer their patients elsewhere.

A good example is the problem we're having now. CMS has instituted these problematic "core measures" we have to do including ensuring that every inpatient over 65 gets a pneumovax shot. This has absolutely nothing to do with Emergency Medicine. However our hospital has told us that we are expected to eval the pts and administer the vaccine to appropriate patients. The fact is that they can't force the admitting docs to do this because if they play too rough the docs will just send their paying patients to another hospital. They can force us to do it by threatening our contract. If we don't do it they'll find someone who will.

Graylin · May 2, 2007

WorkinEM said:
Good Questions. I hate the useless workups on people who are not really sick, the people who use the ER as primary care, the people who use the ER because their outpatient workup wasn't happening fast enough and the adversarial and defensive environment that the med mal crisis puts us in.

Some things that are more EP specific that don't get talked about too much are the PMD dumps when the patient is HMO, uninsured or if they're just complicated and in clinic at 4:30pm.

One thing that has had almost no time on SDN is the fact that as "contract docs" EPs are frequently dumped on by their hospitals. Gas, Rads and Path sometimes get caught in this as well. The issue is that "contract docs" are granted access to the ED (or OR and OR specimens) by the hospital. The hospitals can threaten the contract if you're not willing to do what they want. Contract docs don't have patient panels and can't threaten to refer their patients elsewhere.

A good example is the problem we're having now. CMS has instituted these problematic "core measures" we have to do including ensuring that every inpatient over 65 gets a pneumovax shot. This has absolutely nothing to do with Emergency Medicine. However our hospital has told us that we are expected to eval the pts and administer the vaccine to appropriate patients. The fact is that they can't force the admitting docs to do this because if they play too rough the docs will just send their paying patients to another hospital. They can force us to do it by threatening our contract. If we don't do it they'll find someone who will.

I'll weigh in here as well. No field of specialty is perfect. In all honesty, there is very little that I hate. But I do hate working overnights. Thankfully, I don't have to do to many of them, and I consider it a small price for all the other things I love.

And due to national nursing shortages, I hate that my ED is often short staffed. between that and national health care budgets and cuts, I hate that I can't give my patients the best care they deserve.

WorkinEM · May 2, 2007

postbacker said:
Can both EM mentors comment on pre-meds shadowing in the ER? Do you have time to talk to them? Do you like the inquisitive ones, or the silent observers? Is it possible or practical for someone to shadow an ER doc for his entire shift?

Beyond shadowing, what kind of volunteer opportunities are available in the ER?

Any comments or opinions on this topic appreciated - my first round of shadowing will be in the ER...

Shadowing for premeds is a tricky topic. You really don't know enough to be involved in the medicine of what's going on. For example it would be a waste of time for the doc to spend any time going over an EKG with a premed. Usually the reason premeds want to do it is to secure resume points that show interest and commitment and that's fine. Premeds often pick the ED for shadowing because there are often volunteer programs and it has the reputation of being exciting.

Given that here are my recommendations for shadowing:
-I suggest not trying to go for a whole shift. You'll get more out of going for 3-4 hours segments. Try to go at different times of the night and day to get a feel for what's going on at different times.
-Ask questions but don't feel like you have to. Premeds frequently ask things that get a sideways glance because they don't know any better. I have been asked if I have a "real" job outside the ER and if I'm still a resident (because the student had been told by her doctor dad that residents staffed the ERs back when he was a student).
Good questions usually involve haw the ER works like what does a charge nurse do and how patient flow works. One good question is how the ED recognizes sick patients vs. non-sick patients.

Graylin · May 2, 2007

postbacker said:
Can both EM mentors comment on pre-meds shadowing in the ER? Do you have time to talk to them? Do you like the inquisitive ones, or the silent observers? Is it possible or practical for someone to shadow an ER doc for his entire shift?

Beyond shadowing, what kind of volunteer opportunities are available in the ER?

Any comments or opinions on this topic appreciated - my first round of shadowing will be in the ER...

We have a lot of premeds in our department but that is because we have both a strong volunteer program associated with an undergrad university or two, and we have a research associate program. So, we have tons of them. The ED is a fun and exciting place to be. The one thing to realize is that it is a unique field. The vast majority of medicine does not work or think like the ED. So, although I love the ED, I often give people a word of caution: most of medicine isn't like the ED. If you want a more traditional look at medicine, find a clinic to work in.

Having said that, nothing beats the ED. Asking questions and being interested is good. You just don't want to cross the line to being a pest. Asking questions when the EMP is knee deep in a code or buried under patients isn't the best time. Just relax, dress professionally, take it seriously but have fun. Easier said than done.

Graylin · May 3, 2007

TerraMedicX said:
OK, I've got another question about the EM/IM residencies. I'm applying to medical schools now. I've been in EMS for nearly 8 years with the last four as a paramedic. I will most likly remain in EM, I would be especially interested in an EMS fellowship and teaching/advising for EMS agencies (I've had experiences with great and not so great physician advisors and want to improve prehospital care where I can). I'd also be interested in pre-hospital research.

I realize that plans often change through med school, and I've also considered trauma surgery and critical care as options. The reasons I've been looking at EM/IM residencies is due to the fact that you cannot become boarded in CC with EM alone.

Do you guys know of physicians who work primarily in the ER, but also do CCU? What are the posibilities and options along this road?

Thanks in advance for all your help, I don't know where I'd be without all the great help I've found here on SDN!

Nate.

You are so far away from deciding, that an advice offered is likely to be incredibly invalid in a few years.

As it stands, yes, there are many EM docs who work in the ICU. You can sit for the European critical care boards after a critical care fellowship. There is a huge shortage of ICUdocs and there is a push to make EM people eligable for the american boards. Even without it, I don't know of anyone who has done the EM/CC fellowship that hasn't been able to work.

So, really, I would just focus on doing well in medical school, maybe getting a little research under your belt. Browse both the EM forum and the Critical Care forum, there is good stuff there.

Graylin · May 8, 2007

mtn0417 said:
I have a question concerning post-residency education. No doubt a career as a physician is an education in itself. I have a question with what has a more favorable outcome, cost/benefit wise, going directly into practice following residency or doing an internship/fellowship. I am really unsure of how this works for EM, understanding more of the post-residency stuff from a surgical prespective. I guess I am just looking for your opinion and just views from both perspectives. Is there even fellowship for EM? I know very little on this. Hope you understand. Thanks for taking the time for us, it is all HIGHLY informative!
Although grey's anatomy does give me the most realistic look at what a career in medicine will be like, all the doctors and patients are beautiful right?
-Michael

Micheal-

First off, realize that internship is the first year of your residency. Its a holdover term from when MD's did a seperate year prior to ever doing a residency. Your first year of residency, regardless of specialty, or location is always called internship. Some specialties require a 'transitional' internship year where you do one year of general stuff as an intern and then start your 'formal' residency.

Fellowship is post-residency training. For EM, it is a little different because you tend to practice as an attending part time while you are pursuing your fellowship. SAEM maintains a list of fellowships at http://www.saem.org/SAEMDNN/Default.aspx?tabid=382. You can see what types of things people do.

There are pros and cons to doing fellowship. It delays your financial earnings and is a lot of work. In essence, you must love what you are doing. It makes you more competitive for academic positions but takes more time and work. Its a very personal decision. The key to doing a fellowship is to love what you will be working in. If you don't, then don't bother doing one.

WorkinEM · May 9, 2007

Graylin said:
Micheal-

First off, realize that internship is the first year of your residency. Its a holdover term from when MD's did a seperate year prior to ever doing a residency. Your first year of residency, regardless of specialty, or location is always called internship. Some specialties require a 'transitional' internship year where you do one year of general stuff as an intern and then start your 'formal' residency.

Fellowship is post-residency training. For EM, it is a little different because you tend to practice as an attending part time while you are pursuing your fellowship. SAEM maintains a list of fellowships at http://www.saem.org/SAEMDNN/Default.aspx?tabid=382. You can see what types of things people do.

There are pros and cons to doing fellowship. It delays your financial earnings and is a lot of work. In essence, you must love what you are doing. It makes you more competitive for academic positions but takes more time and work. Its a very personal decision. The key to doing a fellowship is to love what you will be working in. If you don't, then don't bother doing one.

I totally agree. One thing about EM fellowships that's different than other specialties is they don't tend to make you lots of extra $$. A surgeon who goes cardiothoracic will make significantly more money than a general surgeon but a toxicologist won't make that much more than a regular EP. The closest thing to a selfish reason for people to do fellowships is to make them more attractive to academic centers but really you do your fellowship for love, not money.

Graylin · May 10, 2007

rubberducky115 said:
Hi Graylin:

I am a MS4 who did not match into EM this year. I will be doing a Surgery Prelim year, and re-apply next year. Is it harder to get in one year out from med school? My board scores are in low 200's. I received about 15 interviews this year, and ranked 13 - but still didn't match! I think ranking my "dream programs" high up on the list somehow messed up the ranking. Please advise. Thanks.

Unfortunately, there are never an hard and fast rules with the match. This was a really tough year, for some reason. Trying to give an all standing awnser as to why you didn't match is kind of like trying to predict using a crystal ball. So many variables come into play.

PD's know it was a rough year. A year of surgery under your belt will be a good thing. You will need to get some new LOR's that reflect your work as a PGY1.

You also probably need to speak to your EM advisor about why you didn't match- someone who knows your 'whole file'. While your board score is a little low, you can't pin it all on that- especially given that you interviewed alot.

You can't 'mess up the match' by ranking your dream programs high. Its geared to benefit the applicant. If you don't match at your #1, then the match seeks your second, etc. Other programs don't know your match and you can't screw it up by not ranking where you want to go first. This is why consistantly the advice is given to always rank programs in the order you want them.

You need to take a strong look at your entire application: scores, academic standing, research, extra-curricular activities, personal statement, etc. Look at where you applied and make sure you have an even spread of 'dreams', 'competitive' and 'less competative' for you.

try and figure out those things that you can actually do something about. And realize it was a tough tough year. Best of luck.

Graylin · May 11, 2007

Doctor~Detroit said:
thanks for the great advice. i appreciate it.

now that i know that the schools i'm considering would all serve me equally well in getting an em residency, i have the classic debt-versus-happiness question. since you're familiar with academic em (and at this point i think i would like to have this career in nyc), i'd value your input on this.

i've done rough calculations, and figured that after a four-year residency the principal + interest at one school will capitalize at about 200k, and at another school it will capitalize at about 330k. i like the location and the students i've met at the more expensive school subtantially better, and i'm fairly sure that i would have a happier medical school experience there.

at the same time, i'm hesitant that it would be worth the extra 130k of debt in the long run. especially since i don't have first-hand experience with the job market for em (in nyc or elsewhere) and how annoying it would be to pay off the extra money. i understand that this is ultimately my decision and that is a function of what i value, but i'd really appreciate any insight you could offer from your perspective.

thank you!

Before I tell you my opinion, I just want to state the obvious. This is an incredibly personal decision to make. Only you can decide what is best for you. Now, with that stated, I'll be happy to give you my opinion.

I am a gigantic believer in the 'happiness' issue. It is often neglected for various reasons: percieved prestige, finances, etc. However, I believe it to be one of the most important issues. You are about to embark on an incredibly difficult, time consuming, stressful journey that has amazing rewards at the end. But everyone, at some point (and often at many points) will question if the journey is worth it. Anyone who says otherwise is selling you a bridge. Now, with that said, I believe it to be vital to maximize the opportunity of being happy. Your happiness in medical school will make you a better resident applicant. Your happiness as a resident will make you a better applicant for jobs. I believe this to be true because if you are happy, you are more inclined to do extra things, to be motivated, to work better with others.

Debt, certainly, is something to consider. But although to the novice, 130K seems like alot, it really, in the grand scheme of your life as a physician, it is not. If having the extra debt is going to make you a miserable person, that is another story.

the EM market is good. period. It will stay good. NYC is more competitve then it used to be. But being a happy productive med student and then resident, will get you far. Paying off an additional 100K is not going to be that much of an issue. I know that is hard to believe but its true. And your overall happiness, is worth it, in my opinion.

Hope that helps! good luck

EctopicFetus · May 11, 2007

Graylin said:
Before I tell you my opinion, I just want to state the obvious. This is an incredibly personal decision to make. Only you can decide what is best for you. Now, with that stated, I'll be happy to give you my opinion.

I am a gigantic believer in the 'happiness' issue. It is often neglected for various reasons: percieved prestige, finances, etc. However, I believe it to be one of the most important issues. You are about to embark on an incredibly difficult, time consuming, stressful journey that has amazing rewards at the end. But everyone, at some point (and often at many points) will question if the journey is worth it. Anyone who says otherwise is selling you a bridge. Now, with that said, I believe it to be vital to maximize the opportunity of being happy. Your happiness in medical school will make you a better resident applicant. Your happiness as a resident will make you a better applicant for jobs. I believe this to be true because if you are happy, you are more inclined to do extra things, to be motivated, to work better with others.

Debt, certainly, is something to consider. But although to the novice, 130K seems like alot, it really, in the grand scheme of your life as a physician, it is not. If having the extra debt is going to make you a miserable person, that is another story.

the EM market is good. period. It will stay good. NYC is more competitve then it used to be. But being a happy productive med student and then resident, will get you far. Paying off an additional 100K is not going to be that much of an issue. I know that is hard to believe but its true. And your overall happiness, is worth it, in my opinion.

Hope that helps! good luck

Agreed and if you really think about it, if you live your first attending year somewhere between being a resident (45K) and being an attending (185k, for example) living at 115K would allow you to be comfortable and then after taxes you would have 40-50K and that could really pay off debt if it isnt in the sub 3-4% range. Your overall happiness is really important.

I dont know what level of training many of you are in but keep in mind that you will (and I have) seen people who enter highly competetive fields because they didnt want to waste their good board scores and they are miserable. Find a program/med school/ career that will keep you entertained and happy.

wook · May 12, 2007

Graylin said:
Before I tell you my opinion, I just want to state the obvious. This is an incredibly personal decision to make. Only you can decide what is best for you. Now, with that stated, I'll be happy to give you my opinion.

I am a gigantic believer in the 'happiness' issue. It is often neglected for various reasons: percieved prestige, finances, etc. However, I believe it to be one of the most important issues. You are about to embark on an incredibly difficult, time consuming, stressful journey that has amazing rewards at the end. But everyone, at some point (and often at many points) will question if the journey is worth it. Anyone who says otherwise is selling you a bridge. Now, with that said, I believe it to be vital to maximize the opportunity of being happy. Your happiness in medical school will make you a better resident applicant. Your happiness as a resident will make you a better applicant for jobs. I believe this to be true because if you are happy, you are more inclined to do extra things, to be motivated, to work better with others.

Debt, certainly, is something to consider. But although to the novice, 130K seems like alot, it really, in the grand scheme of your life as a physician, it is not. If having the extra debt is going to make you a miserable person, that is another story.

the EM market is good. period. It will stay good. NYC is more competitve then it used to be. But being a happy productive med student and then resident, will get you far. Paying off an additional 100K is not going to be that much of an issue. I know that is hard to believe but its true. And your overall happiness, is worth it, in my opinion.

Hope that helps! good luck

Wook

WorkinEM · May 15, 2007

ajtrau said:
Hello!

I am applying to medical school and had a few question about EM. Currently I work as a Medical Assistant (Nurse's Aide) in a level one trauma center and I absolutely love it! I'm sure things vary from hospital to hospital but I was just wondering what the general job description is for an emergency attending doctor. How many hours do you work a week? It all of that time spent on the floor or are there teaching and/or research responsibilities? Do you have to do a residency in emeregency medicine or can you do something else (like internal medicine)? Anything else I should know?

Thanks so much!

These are pretty broad questions so the answers will be broad as well.

Emergency Physicians (EPs) see all manner of patients who come to the Emergency Department either throught the front desk or by ambulance. Some hospitals segregate trauma and pediatrics but as a specialty EPs are trained to stabilize and treat everything.

Most EPs work 120 to 160 hours per month. This is broken up into shifts that usually are between 8 and 12 hours long. Most EPs work a mix of days, evenings, nights and weekends.

If you work in an academic center you will likely have teaching and research commitments. Some academic groups offer "clinical tracks" where you exchange added teaching and clinical time for research.

Do you have to do an Emergency Medicine residency to work in an ED? That's a complex question because of some political battles that are being fought right now. The basic answer is yes, if you want to work in an ED you have to do an EM residency. The confounding factor is that there are some EDs out there (especially in rural areas) that will hire you without an EM residency. But to be a really viable candidate for the majority of EM jobs you must have done an EM residency.

WorkinEM · May 15, 2007

Hard24Get said:
Dear Graylin/other knowledgeable docs:

Hard24Get said:
I am interested in my home program for EM, but have been told that though the faculty are great, the residents are not "strong".

Thats an excellent question and a tough spot to be in. I will say that Im curious who is saying that the residents are weak. The only real gauge for the quality of a program is the competence of its graduates. If those saying the program is weak are colleagues and directors of the graduates Id be concerned. If its coming for attendings in other departments like medicine and surgery Id give it less credence. Those complaints tend to be more about residents who Dont know how we do it on my service. or how They really screwed up that one patient they called us to consult on. They tend to be more fish bowl gripes that real criticisms about the residents capabilities as an Emergency Physician.

Hard24Get said:
I know part of this is what school they went to (which seems arbitrary),

I disagree. The med school has so much less to do with a residents strength than the residency program.

Hard24Get said:
but what other criteria make a "strong" vs "weak" residents?

Thats the problem. You have to take into account how the person making the criticism is arriving at the strong vs. weak decision. The majority of times Ive seen residents called weak it had to do with some personal disagreement.

Hard24Get said:
How can I tell if the more senior residents are really learning their stuff when it comes to a program?

Thats a great question. If I could totally answer it we could do away with the inservice and the boards.

I will say that you should watch the seniors. Are they comfortable with the basics like intubation, EKGs, critical patients, lines and so on? Do they manage the ED as a whole by prioritizing patients and making sure the flow flows? Are they able to resolve disputes with consultants?

Get the numbers of some recent grads. Ask them how comfortable they were when they got out. Everyone is uncomfortable when theyre fresh out but were they able to function and work through it like most or not.

I cant stress enough that the only real measure of a residency program is the competence of its graduates. Try to figure our if the criticisms are based on that or on some other issue.

Graylin · May 15, 2007

Hard24Get said:
Dear Graylin/other knowledgeable docs:

I am interested in my home program for EM, but have been told that though the faculty are great, the residents are not "strong". I know part of this is what school they went to (which seems arbitrary), but what other criteria make a "strong" vs "weak" residents? How can I tell if the more senior residents are really learning their stuff when it comes to a program?

Thanks!

I don't have a lot to add to what WorkinEM said. It really is contextual. Who is saying 'weak'?

Strength in residency has almost nothing to do with medical school and everything to do with residency. I think the advice to talk to graduates is crucial.

Basically, ditto what he said.

WorkinEM · May 17, 2007

Helpyy said:
Anyone knows any medical schools for EM which accepts the lowest grades and what are the minimum grades they accept?

Medical schools don't take students for specific specialties. If you want to do EM you have to get into medical school and then, in your fourth year, you apply to residencies in whatever specialty you choose.

If you're asking about which med schools might accept someone with poor grades in college you might do better addressing your question to the pre med forums.

If you're asking which EM residencies accept candidates with poor grades that's a tough one. EM is pretty competitive these days so if you have some glaring defencies in your med school or board records getting into an EM residency will be harder.

Graylin · May 17, 2007

drox said:
This is a question I was thinking about for a long time. I am aware that FP physicians can do a 1 year fellowship program in Emergency Medicine. In that case, can such FP docs work as ER physicians?

'
This is a somewhat controversial topic. There are one or two fellowships for FP doctors to do. However, you are not eligable to sit for the Emergency Medicine boards. You can not become board certified in EM without doing an EM residency.

There are small ER's in rural locations that will hire FP's to work in the ED. In the legal area, this may become harder and harder.

You might try adressing this in the FP forum where people have more experience as FP's. You can also search in the EM forum as there are several threads that discuss this.

WorkinEM · May 17, 2007

drox said:
This is a question I was thinking about for a long time. I am aware that FP physicians can do a 1 year fellowship program in Emergency Medicine. In that case, can such FP docs work as ER physicians?

The "fellowship" that FPs can do does not lead to board certification in Emergency Medicine by the American Board of Emergency Medicine or any board recognized by the American Board of Medical Specialties.

There are non-EM trained docs who work in EDs. These are predominantly rural or otherwise underserved EDs that have to take what they can get. Docs with these "fellowships" or docs who are "board certified" by unrecognized orginizations like the American Board of Medical Specialists are not competitive for the vast majority of jobs in Emergency Medicine.

There have been many, often heated, discussions of this issue on the EM and FP forums. Here's an example:
http://forums.studentdoctor.net/showthread.php?t=381970&highlight=board+certification

Here are some other useful sources of primary info to give you an idea about the controversy:

http://www.abpsga.org/index.html

http://www.acep.org/webportal/membe...2005/CertificationIssueRekindledinFlorida.htm

http://www.aaem.org/positionstatements/abdm.php

http://www.em-news.com/pt/re/emmedn...ovft&results=1&count=10&searchid=1&nav=search

http://www.em-news.com/pt/re/emmedn...ovft&results=1&count=10&searchid=1&nav=search

BTW Greylin and I answered this at the exact same time which is why there are 2 replies.

deleted6669 · May 18, 2007

WorkinEM said:
We use PAs. Our PAs get flat salary and the supervising docs get the patient billing. Other places do it differently to incentivise the PAs to see more patients. Our program has every patient get seen by the supervisory doc at some point in their ED stay. Other places don't but then you can only bill for the PA visit which is about 70% of a doc visit.
Groups change what they do based on their volume, staffing and payor mix.

I am an em pa who works at a busy trauma ctr on the west coast.
The bill for the pa seeing the pt alone is 85% of the md bill.
we are paid hourly plus production bonus. In our system the pa's only present the pts they want to get consults on. our pa group is all very experienced folks with no new grads. most of us have prior experience as paramedics and we are all certed in acls, atls, pals, fccs, and the difficult airway course. we see fast track and moderate acuity(belly pain, bleeding in preganancy, worst h/a ever, etc) types of pts. the docs staff the critical area and see probable mi's, cva's, and multisystem trauma. we see almost everything else. we also run an ed obs unit where the pa's do treadmill screenings on "low risk" chest pain pts. we all do very well salary wise( last yr the pa salary range was 110-160k) but we make the docs significantly more money than it costs to pay our salary and benefits packages. it's a great deal for all of us.

WorkinEM · May 19, 2007

nvshelat said:
This is a great forum and lots of questions that I've had have already been answered.

To the EM physicians: In regards to the balance between the breadth of knowledge and depth of knowledge in EM, does it ever bother you that you may not know everything about a particular illness or say mechanism of disease? The reason I raise the question is because I myself (an MSI) am unsure if I see myself in a field where I could have time to think about a disease, look up current research in the area, etc; or if I see myself being more hands on and moving on to the next patient. Just curious about your personal perspectives on this tradeoff.

I hope this makes sense!

That's a good question. This is actually a version of the old "triage nurse" criticism levied at EPs by the rest of the world. My answer is that it does not bother me in the slightest that I'm not the definitive doc on most of my patient's issues. Most of us in EM joke about having short attention spans and there's some truth to it. We don't generally like working up problems to their conslusions. We like evaluating, stabilizing and dispositioning.

Even though we are not the definitive docs we are the only docs with the skill set to do what we do. We are ready to deal with anything that rolls in, day after day. And it can be anything. Trauma, peds, OB, burns, psych, tox, anything. I feel that we are the best at emergent airways. In many centers we run all the codes and do all the tubes. We are able to run an ED and prioritize patients and keep the flow going.

Graylin · May 21, 2007

nvshelat said:
This is a great forum and lots of questions that I've had have already been answered.

To the EM physicians: In regards to the balance between the breadth of knowledge and depth of knowledge in EM, does it ever bother you that you may not know everything about a particular illness or say mechanism of disease? The reason I raise the question is because I myself (an MSI) am unsure if I see myself in a field where I could have time to think about a disease, look up current research in the area, etc; or if I see myself being more hands on and moving on to the next patient. Just curious about your personal perspectives on this tradeoff.

I hope this makes sense!

I would argue against these assumptions for a couple of reasons:
1- No one physician knows everything about a disease or the totality of the mechanism.
2-It is a rare shift where I don't look up current research in my field. For EM docs, skills must even be finer honed because while I look in EM journals, I also look in cards, ICU, etc journals for my literature. (PICO is my friend) EMP's must be well versed in many areas and thus must draw from many areas of research. If you are an EM doc who just moves through patients, never looking up literature, etc, you are a danger to your patients.
3. As WorkinEM said, the 'triage' concept is old world and not applicable. Does it bother me to not always now the diagnosis? No, but niether do IM, ICU, etc docs sometimes. It just happens a little more often in the ED.

Hope that helps!

Graylin · May 21, 2007

cgscribe said:
I'll be an entering MS1 this fall, and I think it's great they have this forum. I've worked as a "Scribe" the last couple years in Fresno, and have really enjoyed my time working with the ER Docs. I had a couple questions:

1. Is there a shortage of EMP's at academic centers for teaching/research? I'm just curious how competitive the academic environment is.

2. What are your takes on the proposed universal healthcare plans? I'm specifically interested in how a universal plan would affect reimbursement for Emergency docs.

Thanks for your help, I look forward to being a regular reader.

Right now, there isn't a shortage of EM docs. Academic positions are more competitive but there isn't a shortage of positions. It really depends on the market. Some are locked very tightly, others are more open. It seems to be in a balance right now, overall. Academics is definately becoming more competitive though and gets more so each year.

I will be honest, I have definate ideas of where I think health care should be. However, I am not a health care policy person. One of the reasons I particularly like EM is we (I) get to hide behind emtala. I don't think about people's insurance, etc to determine my care. I give the best care and that's it. I know its a little bit of head in the sand, but it was one of the reasons (out of many) that I picked EM. I like caring for all patients, not just the ones that can afford it.

Maybe someone else can give you a better awnser to this question.

Graylin · May 24, 2007

nvshelat said:
Hi,

So it seems as though my plans for research this summer (after my first year of MS) fell through since it was to take place at another institution, and my school would only cover me for medical malpractice if I did clinical research through my school. Anyway, I'm wondering if not doing research this summer would make it more difficult for me to land a competitive EM residency? How much are research/publications weighed in your decision to accept a resident (assuming all else is in order)?

Thanks!

how much research is weighed in is highly dependent on the programs you apply to. Some will weigh it heavily, others not so much. Research never hurts. However, you shouldn't fall into the 'checking boxes' mentality. Do research if you are passionate about it. People who don't love research do crappy research and it shows. Or when you are asked to speak about it, it becomes immediately obvious that you weren't really into it. If you love it, you will find ways to do research. Between your ms years is not the only time.

If you don't love research, spend your time doing something you love.

I'm not sure why malpractice is necessary to do research. Even clinical. We have approx 60 research associates every sememster in our ED conducting research and none of them have 'malpractice'. You only need this when you are doing direct patient care.

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