Floor month. Worthy?

deleted109597 · Dec 24, 2009

So as not to overdo the interview commandments thread, allow us to discuss this here.
I, for one, feel that floor medicine months are not useful for emergency medicine. The reasons are as follows.

1. I went to medical school, so I already saw 12 weeks of mandatory inpatient medicine. Some may have had fewer, but still, they didn't have zero.
2. You admit every 4th day. Big deal. I admit every day in the ED. I do their full H&P in the ED as well.
3. You end up being a secretary. Seriously, at my facility they want you to dictate discharge summaries, then manually type a note into the computer system that the clinics use. If that note isn't there for their followup appointment, they call the person who did it to come see them in clinic (doesn't matter to offservice, but still, a dumb rule at best). Also, you have to call the clinic to get them their appointment. You can't just tell the patient to call. I guess the logic that follows is that I should drive them to the pharmacy to fill their scripts, watch them take them, and the drive them to their appointment, since I can't trust them to make their appointments to begin with.
4. 4 hour rounds? Really? I don't care why their K is 3.6. That isn't even abnormal. Jesus, just stop talking already.
5. Without sounding more calloused than I already do, I don't care how their hospitalization goes. As long as I don't do something stupid at the beginning, none of the rest really matters to me.
6. Nothing like listening to people complain about the place you work every day. I got it, you don't like the ED. Tough, it pays your salary once you're in private practice. And no, I didn't order steroids.
7. You spend more time learning to "be a wall" than you do learning medicine.
8. What is it with the lack of attendings during the afternoon/evening? I mean, if I want to learn from residents, I want residents who, you know, do what I do. Not residents who obsess over complement levels.

So far the only thing going for it is the concept that everyone in residency is in a **** sandwich together, and the more you work with the "others", the easier it is to be nice to them when you need to. However, it also makes it easier to be mean to them when they're being dickheads.

roja · Dec 24, 2009

My .02, reposted:

I think statements that 'doctors who do floor medicine are better than those that don't' is a bold tenet. It is inaccurate, educationally unsound and generally has no real truth to the statement. NO rotation guarantees that a resident will come out better. As I have stated before, the point of residency is to create opportunities that increase the liklihood that residents will learn and be exposed to the things that will make a good emergency physician. What this is will vary from learner to learner, based around a core base of knowledge (emergency medicine, determined by the RRC. These are criterion standards created by the field) To insinuate that by default, all graduates of programs that have no floor months are inadequately trained is a huge leap... and the reverse, that all graduates of floor month programs are competent is also faulty.

However, there are educational pros and cons that can be discussed around floor months. As Socute and others point out, learning the systems component can be valuable (although this will change when you change your practice environment). There is also important interpersonal bonding that can happen. However, this may not be necessary. Some places already have solid relationships between medicine, surgery etc that don't require 'bonding' and many residents will already have a good understanding of what the 'otherside' experiences. In truth, ANY rotation has educational potential that can make us better physicians. Neuro-optho, optho, ENT, peds onc, gyn onc, CT surgery, vascular surgery, rheum, derm, rads... the list could go on and on. There is no field that doesn't at some point touch us in the ED. But the reality is that CORE EM material has to be learned and at some point we have to start practicing. Each learner has to assess what is important to them, weigh the type of learner they are, what skills they feel need over others and make a decision. That is why the 'there is no perfect program or top program' discussion happens over and over again.

In essence, for learners, ward months have potential to be benificial. But they are not necessary to become a well trained physician, and they in no way gaurantee that a resident is better trained.

xaelia · Dec 24, 2009

For "learners", those motivated, ideal doctors who find the marble in the oatmeal of any rotation - yes, they will find value in their floor medicine month. They may also find value in any other number of rotations, particularly ones that didn't drain their soul with endless scut, social work, and overnight call.

The question is not so much whether medicine floor months have educational value, but whether their relative value is greater than its alternative (or Value Over Replacement Rotation Month [VORRM] in baseball terms).

energy_girl · Dec 24, 2009

I was initially REALLY opposed to the idea of doing floor months for all the reasons the OP mentioned. Now that I'm halfway through intern year, I have a slightly different perspective. First, my floor months have been really good in teaching me how the other service thinks. I notice that I do a better workup and give a better passoff because I know what I would have liked if I were on the other end. EM care is the beginning of a continuum on care, and it's useful to see the other end of it. Second, the off-services have fantastic teaching. They devote more time to it than we can in the ED. If you can see rounds as teaching opportunity, it goes by much quicker. Third, it's a good way to meet residents in other fields; makes our consultant interactions tons easier.

Still, though, floor months are painful, so I totally hear ya!

howelljolly · Dec 24, 2009

I think that floor rotations are essential in EM. Realize that you are in academic medical centers which may or may not allow the ED to admit the patient (vs. the inpatient team choosing to admit the patient). Point is that you have lots of help, and an inpatient housestaff team which will follow the patient regardless of how bogus, unnecessary, or economically inefficient the admission is. And the next day, the team will round and discuss the patient's K ad nauseum, and they'll like it.

Once you get into the real world, in a small community hospital with no residents, where you have to call private attendings to admit the patient.... If you don't have a clear understanding of what the internist can/will do with the patient, you really are going to waste everyones time.

Think of how it feels to the ED attending when Psychiatry refuses to accept a patient because their glucose is 250 and has been for 10 years. Well, it MIGHT be the DM. But you simply aren't going to fix their blood sugar. This shows a lack of understanding by Psych of how medicine works.

Similarly, EM docs need to have a clear understanding of how inpatient medicine works if they are going to admit a patient. Sure it MIGHT be XYZ, but will that be fixed in the hospital over the next couple of days? This sort of problem happens all the time in small non-teaching community hospitals. I think it can be taken care of with more inpatient training.

Just my dos pesos.

RxnMan · Dec 24, 2009

howelljolly said:
I think that floor rotations are essential in EM. ...Think of how it feels to the ED attending when Psychiatry refuses to accept a patient because their glucose is 250 and has been for 10 years...This shows a lack of understanding by Psych of how medicine works...

To play devil's advocate, by that reasoning EM-docs-in-training should do rotations in every field we admit to. Which would mean a psych rotation, peds inpatient, and a bunch of others. Do we need to spend a month on every one?

howelljolly · Dec 24, 2009

RxnMan said:
To play devil's advocate, by that reasoning EM-docs-in-training should do rotations in every field we admit to. Which would mean a psych rotation, peds inpatient, and a bunch of others. Do we need to spend a month on every one?

Good point. But I dont think so. Adult inpatient would give you the most bang for your buck. And the other services that EM admits to probably get more involved in the admission itself, so its probably less of an issue... Psych, heme-onc... And when you admit to those services, you have a pretty compelling reason to. The more debatable admissions -for observation, or to work something up that could be done outpatient - those go to general medicine.

Peds... just admit them. Nobody can figure those kids out.

glorfindel · Dec 24, 2009

Dr.McNinja said:
Also, you have to call the clinic to get them their appointment. You can't just tell the patient to call. I guess the logic that follows is that I should drive them to the pharmacy to fill their scripts, watch them take them, and the drive them to their appointment, since I can't trust them to make their appointments to begin with.

I always wondered about this.

The spectrum of post-discharge things that could be done for patients is very broad. At one extreme, you could just hand them a bunch of scripts and tell them to get out. At the other extreme, you make all their appointments for them, arrange rides to the clinic, resupply their refrigerators, clean their carpets, etc. Why do we draw the line where we do?

For example, you might think that if your goal is to ensure outpatient follow up, it would be best to have the patients make their own appointments. They know their own schedules best, after all. Has anyone ever studied this? Does making appointments for inpatients about to be discharged increase the percentage of discharged patients that follow up?

But, returning to the main point....

Floor months are not worthless, but they're very low "bang for the buck." Certainly when compared to ICU months. Medically, there's just no contest. Socially, I suspect you can bond better with your medicine colleagues by getting in the pit with them in the ICU than you can by rotating on the floor.

Sure, everything's valuable, but time is limited and you need to concentrate on the most valuable training opportunities in light of your goals.

Pure Anergy · Dec 24, 2009

Personally, I don't have strong feelings either way. Floor medicine is not what I would pick first if I could pick the off-service rotation that I absolutely most want to do for a month. But at the same time, it's not so horrible or pointless that I would be willing to claim it's not worth doing.

There's something else to consider that no one has brought up yet. Sometimes, when you're at the bottom of the training totem pole, you have to have a little faith that the people above you do have some iota of a clue about what they're doing. Maybe not a huge clue, but probably more than your clue. When you're so close to the ground, you can't always see the entire landscape due to your own ignorance of what else is to come. This point was driven home to me in med school when some of the "stupid" things they made us do suddenly became useful later. It's frustrating to not understand why you have to do something, but there's usually a reason for it, even if it's not completely accomplishing its goal. So, if wherever I end up requires a medicine month, I'll do what they ask me to for four weeks and hope it will pay off in the long run like they think it will.

Even if you're one of the people who utterly hates your medicine month, look at it this way. When you get back down to the ED the following month, you'll be super-appreciative of how good you have it compared to those poor medicine residents.

turtle md · Dec 24, 2009

We called it the "Emergency Medicine reaffirmation month." Then we voted to get rid of it, so subsequent generations wouldn't have to waste their time. We replaced it with an additional MICU month. From what I have heard, the residents feel this is a great improvement and much higher yield.

Tiger26 · Dec 25, 2009

turtle said:
We called it the "Emergency Medicine reaffirmation month." Then we voted to get rid of it, so subsequent generations wouldn't have to waste their time. We replaced it with an additional MICU month. From what I have heard, the residents feel this is a great improvement and much higher yield.

Given two equally great programs, if one had a floor month and the other had another unit month, I'm picking the unit one every time.

Not that I couldn't learn from a floor month, but I want as many high yield opportunities that I can get since I'm already getting the feeling that 3 (or 4) years of residency is going to go by really quick . . .

nymbarra · Dec 25, 2009

My floor medicine month was a lot like being in med school again. I liked it for several reasons:

- learning the system as others have mentioned helps with finding resources for your patient after discharge, e.g. I get HomeHealth a lot in the ED if I feel that my patient can get a resource that prevents another ED visit
- working with your medicine colleagues on their "turf;" they do the same in the ED, and mutual understanding goes a long way
- I had a young attending who believed in card-flipping/table rounds, and only when there was an interesting physical finding did we see the patient
- as a result I had a lot of free time to read, something that you don't usually have in the ED
- we also had noon conference every day (with free catered lunch), another hour to chill and learn

Beyond that, I agree with Tiger, a unit month is much more valuable than a floor month.

I do like that some programs do a cards or renal month. We see so much cardiac and renal disease that it could be valuable. I did both as electives as an MS4, and I got a lot of teaching from both.

Jeff698 · Jan 2, 2010

4 1/2 years in the rear-view mirror, I look less harshly on my floor months than I did right afterwards. I think I learned from them. Some.

I learned about admitting orders, something I didn't know very well from medical school. I learned how much of being a hospitalist is social work (probably more than being an EP, those poor souls). Most importantly, I got to know the faculty and fellow residents I'd be working with in the future. By sharing the hell of internship (let's face it, being an intern in any specialty sucks) with medicine residents formed a bit of a bond. It made my calls to them the next several years much better.

Now, as a faculty, when I call them for an admission it is a much more pleasant call.

Take care,
Jeff

pinipig523 · Jan 13, 2010

I think floor months definitely help.

You get a different perspective of care - you see how it is on their end of the continuum. You realize that maybe I should order iron panel studies before I transfuse the guy because the floor loses their ability to differentiate the anemic etiology, etc.

It's nice to think that we're our own little cocoon of care providers and that we shouldn't really think too much of what goes on beyond the ER, but if it's patient care we're truly after - it's best to have a good idea of what happens on the floors as an admitting service.

Floor month. Worthy?

deleted109597

roja

Full Member

xaelia

neenlet

energy_girl

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howelljolly

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RxnMan

Who, me? A doctor?

howelljolly

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glorfindel

Have you walked your dog?

Pure Anergy

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turtle md

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Tiger26

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nymbarra

In flux

Jeff698

EM/EMS nerd

pinipig523

I like my job!

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