"Not a lot of handholding"...

whether you're thrown in the pool or climb in using the ladder, you'll eventually learn to swim. the questions that you're asking about are too broad, though, to have a single answer other than "it depends." none of those questions are deal-breakers, though. Study and work hard and you'll have no problem working in the ER.

In my experience, though, I've not seen a lot of this "left flapping in the breeze" type of behavior. most attendings or seniors I've met in the ER are usually very helpful, especially during intern year when they realize that you're not going to be able to fly through patients at 2.2395 per hour or work up complicated patients without any assistance.

I interviewed at a ton of programs, and I got the feeling that there were very few places where an intern was left "flapping in the breeze" when there waas someone who was supposed to be supervising. The biggest variation was whether the supervising physician was a senior resident or an attending physician. Places with a senior resident might actually have MORE supervision (since new supervisors can be a bit nervous and overly hands-on).

The level of hand-holding is dependent on how good you are at things.

Granted, your 3rd and 4th years of medical school, there's gonna be a good amount of hand holding, but nobody expects you to come in and run a code, then insert the lines, etc as a med student. Your job is to learn how the ED works, see a few patients, and ask a ton of questions.

Some interns come through knowing more and having a better feel for things than others....it's how well you comprehend the flow, know what your role is, and pick up on the way things are done. Sometimes, it's just how good of a learner and how good the skills are.

I did a boatload of EM as a med student. My school (a DO school) allowed us to substitute EM for medical/surgical selectives, and even for primary care (one of our rotations was "peds", but it was in a peds ED, so you could substitute it for "peds" and they didn't care). After like 8-10 rotations, I felt more comfortable, but still wasn't ready to run the show or anything.

EM isn't something you can just jump into like medicine or FP or something and be reasonably good at. It takes time to get your sea legs with it. You have to learn the nuances of doing things, the physical exam nuances, the nuances of getting a good H&P in a few minutes while doing the physical exam at the same time (checking neuro while you talk, etc). After 3 years of residency (in a DO program), do I feel ready? Hell yeah. Did I feel ready after a couple months? Hell no. It just takes time.

When you're a student, just ask how things work. Watch how the good interns and residents do things and watch the good attendings. That's how you'll figure things out.

another helpful tip: ask them what this means. 'hand holding' might mean very different things to different people.

Be careful about programs that brag about autonomy given to junior residents. Speaking as a junior resident myself we don't need autonomy we need supervision.

This whole idea that an intern thrown into the mix so-to-speak will just sink or swim is bullsh**. Patients are too sick and too complicated and you haven't seen enough of them to manage things appropriately. The intern who desires free reign to take care of the average load of ED patients is the intern who is all set to kill a few people.

AmoryBlaine said:

Be careful about programs that brag about autonomy given to junior residents. Speaking as a junior resident myself we don't need autonomy we need supervision.

This whole idea that an intern thrown into the mix so-to-speak will just sink or swim is bullsh**. Patients are too sick and too complicated and you haven't seen enough of them to manage things appropriately. The intern who desires free reign to take care of the average load of ED patients is the intern who is all set to kill a few people.

Click to expand...

exactly.

autonomy comes with time........and that time is not in the first 2 or 2.5 years.

AmoryBlaine said:

This whole idea that an intern thrown into the mix so-to-speak will just sink or swim is bullsh**.

Click to expand...

Good point. It is the patients who end up doing the sinking.

But for the grace of my supervising faculty, I would have frequently contributed to the negative buoyancy of my patients during my internship.

Take care,
Jeff

DaveinDallas said:

Ok - Thanks for the insights.

I do have another question - I'm in a position where I'm probably going to need audition rotations at the programs I'm interested in (i.e. average grades/board scores - COMLEX I only thus far. I plan on taking USMLE Step 2 in addition to the required COMLEX Level 2). What would be a good basic level text to start off with to be a step ahead of the game? Is that even advisable or just be eager and willing to get involved? What did your programs look for when they saw someone in my position? Can hustle really make up for other deficiencies?

Click to expand...

To take your questions one by one...

Basic level text: This topic has been discussed multiple times with no real conclusions. The two that seem to pop up a lot are Emergency Medicine Secrets, and the Oxford Handbook of Emergency Medicine. The Tarascon pocket books are also popular, but probably more useful as a quick reference to someone who already has a good knowledge base. Do a search for more info.

What do programs look for on rotation: Work hard, play well with others, be curious but not overbearing, read when you've got time (both during and after shifts...), never EVER waste time on shifts (don't check your email 14 times per hour, etc.), show interest in the area you're doing your rotation ("Oh... I've always WANTED to move to Saskatchewan!")

Can hustle make up for other deficiencies? Short answer: yes with a but, long answer: No with an except... Can it make up for small/medium deficiences? Absolutely. Can it make up for glaring lack of knowledge/interest? Probably not. You sound like you're in the former category so if you bust your butt and get good letters and apply widely you should do okay.

Greenbbs said:

The level of hand-holding is dependent on how good you are at things.

Granted, your 3rd and 4th years of medical school, there's gonna be a good amount of hand holding, but nobody expects you to come in and run a code, then insert the lines, etc as a med student. Your job is to learn how the ED works, see a few patients, and ask a ton of questions.

Some interns come through knowing more and having a better feel for things than others....it's how well you comprehend the flow, know what your role is, and pick up on the way things are done. Sometimes, it's just how good of a learner and how good the skills are.

I did a boatload of EM as a med student. My school (a DO school) allowed us to substitute EM for medical/surgical selectives, and even for primary care (one of our rotations was "peds", but it was in a peds ED, so you could substitute it for "peds" and they didn't care). After like 8-10 rotations, I felt more comfortable, but still wasn't ready to run the show or anything.

EM isn't something you can just jump into like medicine or FP or something and be reasonably good at. It takes time to get your sea legs with it. You have to learn the nuances of doing things, the physical exam nuances, the nuances of getting a good H&P in a few minutes while doing the physical exam at the same time (checking neuro while you talk, etc). After 3 years of residency (in a DO program), do I feel ready? Hell yeah. Did I feel ready after a couple months? Hell no. It just takes time.

When you're a student, just ask how things work. Watch how the good interns and residents do things and watch the good attendings. That's how you'll figure things out.

Click to expand...

Does anyone know how many schools, both osteopathic and allopathic, do this?

LastPolarBear said:

Does anyone know how many schools, both osteopathic and allopathic, do this?

Click to expand...

It doesn't seem very common amongst allo schools, although I attend one that does allow EM to count as your medicine selective. It's a good thing too or I might be locked up on a ward somewhere if I had to do one more medicine month as a med student. Most students from other schools whom I've spoken to, however, were astonished that a formal medicine sub-I wasn't required for us.

I'd advocate against substituting EM for other rotations. There have certainly been times sitting in Neuro clinic when I'd rather be in the ED, but getting through that taught me a lot about doing a good neuro exam. Same goes for some of my surgery rotations, peds etc. Yeah a peds emergency rotation is cool, but you still have to understand how that new onset diabetic is going to be managed on the floor to be most effective in the ED.

I would certainly advocate seeking out rotations within med school that are more applicable to EM. So for surgery electives I did cardiac and ortho (vrs something like urology or endocrine), for neuro I spent some time with neuro surgery etc.

If you are going into EM you'll do that for the rest of your life, med school might be your only chance to scrub on brain surgery or do an infectious disease rotation.

LastPolarBear said:

Does anyone know how many schools, both osteopathic and allopathic, do this?

Click to expand...

back when I was at LECOM, there were ways to skirt the system (and I believe there still are).

Our peds rotation as a MS3 was in a peds ED, although it counted as peds....so, since it counted as peds, you could do that as a primary care selective, etc. I'd much rather do peds EM than office based peds.

EM counted as a medical and surgical selective as well at that time, because they could say that it fit the best of both worlds. In addition, I did cardio, GI, heme onc, as medicine type electives in med school

I had to do 2 months of required EM rotation as a MS4.

I had 2 electives my MS3 year and 4 my MS4 year, which i did one EM as a MS3 and 2 EM as an MS4.

All in all, i did 2 months of "peds" em and an adult month as a MS3, and in the MS4 year i did 4 months of adult EM, 3 months of peds EM, so 10 in total.

jbar said:

I'd advocate against substituting EM for other rotations.

Click to expand...

I agree completely. As much as those rotations pained me, I learned alot during them.

Be careful as a medical student not to fall into the trap I did. I was very sure of what I did and did not "need" to know. Turns out I was wrong pretty often.

Take care,
Jeff

Wait, are you saying that the people who had done this for years knew more about what you needed to learn than you did? No way. I "knew" what I "needed" to know as a student a little much as well. funny.

Jeff698 said:

I agree completely. As much as those rotations pained me, I learned alot during them.

Be careful as a medical student not to fall into the trap I did. I was very sure of what I did and did not "need" to know. Turns out I was wrong pretty often.

Take care,
Jeff

Click to expand...

I think that whether subbing in EM (or any other similar "ambulatory" type rotation) for a traditional 4th year sub-I is wise depends a lot on the experience you had during your 3rd year. If you attend a school where you do two months of medicine, surgery, peds, FP, OB, and psych (or neuro or both), then that supplemental 4th year inpatient sub-I may be less important than if you have a different curriculum where less experience in the core fields is obtained. Personally, we do two months of inpatient medicine and I felt like that was sufficient medical school experience since I will be doing one inpt. medicine month as an EM intern. Not to mention that I was the only student on the team with an intern who liked to take a LOT of time off, so by default was basically a sub-I for a month. I would definitely say that this only applies to ward-type rotations; a critical care rotation is very important for learning how to care for those patients (and for me was much more interesting as well).

DaveinDallas said:

So I'm sitting here narrowing down what I want to be when I grow up and am coming to a realization about how effing little I really know and how much I go through the motions (how many 3rd years can REALLY hear a heart murmur? Based on my classmates, not too doggone many unless it's a grade 5).....

Unless something really bad happens in my core emergency medicine rotation, I've decided on emergency medicine.

Ok, great --

I've been talking with a few residents at various programs and have heard the phrase,"There's not a lot of handholding here." or a variant on that theme "They'll leave you flapping in the breeze if they think you're not trying..." etc.

My questions are: 1) What is really expected of an intern in most EM programs? and 2) Should I interpret that statement as saying that I'd pretty much be an autonomous agent expected to get help when I needed it - i.e. run my plan and finding past my upper level BEFORE I go off and initiate therapy or as a 'get to work, I'm busy, don't but me' type of deal?

As I've said throughout 3rd year, it's a world of difference when YOU are responsible for the patient vs. doing the student thing.....

Click to expand...

Every program will have a mix of attending styles...some are more aimed at walking you through the patients and others are interested in giving you autonomy to make decisions, including minor mistakes, to allow you to learn. I very much doubt that you will find a program where you can't say "i need some help here" and are ignored. Most attendings respect the request for help/teaching more than someone bumbling through their care of the patient.

Clearly you already appreciate the heavy mantle of responsibility placed on you to 'do no harm'...that is your first and most important step of being a good doctor. It sounds like BS to most of your colleagues until they are in a bad situation. I really do use the principle daily in my practice, often explaining to families the limitations of our care and my desire to 'do no harm' to their loved one.