"All Programs Will Prepare You Equally"

[Thereisaspoon]

"All Programs Will Prepare You Equally"

Does anyone actually think this is true?

I've seen such wide variability in acuity, bedside teaching, didactics, sim, and resident/attending badassery at different programs, and I just can't believe that it's true. I rotated and interviewed at several programs. There are programs where residents meet their procedure numbers by the end of first year and other programs where they're hard pressed to do so by the end of second. There are programs where the resident run codes demonstrate particularly excellent leadership, control, and calm.... There are programs with a 2% ICU admit rate and others with 5x that amount. There are programs with heavy ICU exposure, no floor months, and limited ED scut and other programs that scut you out to other services for a cumulative year. Unfortunately some of the programs I perceive to be the best are also not in the best locations. As I make my ROL, I find myself torn between the places I perceive to have the best training and those that I perceive will offer a better lifestyle for myself and family.

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[Zebra Hunter]

I've never heard that quote. I have heard "Most programs will make you a competent emergency med physician".

 

[coachB]

"All Programs Will Prepare You Equally"

Does anyone actually think this is true?

I've seen such wide variability in acuity, bedside teaching, didactics, sim, and resident/attending badassery at different programs, and I just can't believe that it's true. I rotated and interviewed at several programs. There are programs where residents meet their procedure numbers by the end of first year and other programs where they're hard pressed to do so by the end of second. There are programs where the resident run codes demonstrate particularly excellent leadership, control, and calm.... There are programs with a 2% ICU admit rate and others with 5x that amount. There are programs with heavy ICU exposure, no floor months, and limited ED scut and other programs that scut you out to other services for a cumulative year. Unfortunately some of the programs I perceive to be the best are also not in the best locations. As I make my ROL, I find myself torn between the places I perceive to have the best training and those that I perceive will offer a better lifestyle for myself and family.

Go to one of the programs that will give you the best training. Get your ass kicked for a few years and you will benefit for the rest of your career. That said, I don't buy into the idea that floor months are a negative. You learn a perspective from them that you can't get any other way. It is obviously dependent on your role on those services, but having trained at a program that is relatively heavy in off service rotations, I think I learned a lot. The pendulum has swung a bit too far in the other direction in my opinion. As for location, pick one that's tolerable, but you can choose where you want to live for the rest of your life. And no, all programs don't prepare you equally, not even close. However, to the vast majority of employers, administrators, etc, that is indeed how they see things. One board certified doc equals another. We are all just replaceable cogs in the machine.

 

[goodoldalky]

I've never heard that and I would say that's not true.

 

[EM4life]

I agree you cannot say all programs prepare you equally. Every EM residency program has been vetted and should train you to become a competent ED physician - but as those practicing will tell you, there is a HUGE variability as far as what kind of environment you will be working in - trauma centers versus small rural EDs versus busy inner city EDs that see a lot of urgent care - some programs will train you better than others for different environments. I have seen ED doctors who cannot handle volume of minor complaints but can manage the critically ill like no ones business and the other way around. I would look into programs that offer you the widest variety of experiences, and if that's not possible, look to the program with the sickest patient population.

 

[erdoc00]

Not all programs prepare you equally, but that doesnt necessarily mean what you think.

A high acuity county program may prepare you great for penetrating trama and critical care, but once you get out in the community, you'll find these skills arent the most helpful. Ideally you should train in the environment you see yourself working in as an attending.

Also, regarding off service months... as far as im concerned, ER residencies need MORE off sevice months. The ER doesnt have its own set of separate medical problems; rather every problem falls under some specialty. I think primarily training in the ER is less efficient and less effective than working off service. It would be like a guitarist only learning to play chords and never practicing scales or learning music theory.

ER is a specialty made of other specialties. The day to day work is only slightly variable. A month on ortho will give you more exposure than a year in the ER to orthopedics; not to mention when youre in ortho you'll actually have the time to learn more instead of trying to learn while grinding in the ER. Same goes for ophtho, ent, ob/gyn, anesthesia, etc... much more efficent to be offservice with these services rather than hoping to learn by limited exposure and luck while in the ER.

Few of us like to be offservice, but from a learning perspective, I personally think we do ourselves a disservice by limiting our offservice experiences.

 

[Birdstrike]

"All Programs Will Prepare You Equally"

Does anyone actually think this is true?

I've seen such wide variability in acuity, bedside teaching, didactics, sim, and resident/attending badassery at different programs, and I just can't believe that it's true. I rotated and interviewed at several programs. There are programs where residents meet their procedure numbers by the end of first year and other programs where they're hard pressed to do so by the end of second. There are programs where the resident run codes demonstrate particularly excellent leadership, control, and calm.... There are programs with a 2% ICU admit rate and others with 5x that amount. There are programs with heavy ICU exposure, no floor months, and limited ED scut and other programs that scut you out to other services for a cumulative year. Unfortunately some of the programs I perceive to be the best are also not in the best locations. As I make my ROL, I find myself torn between the places I perceive to have the best training and those that I perceive will offer a better lifestyle for myself and family.

"All Programs Will Prepare You Equally"

I will say, "Yes, they do," but with the caveat that, "Some may do it worse than others."

If that doesn't seems to make sense, let me explain. As much as you might like to think your days of "self teaching" like you had to do in medical school are over, you're wrong. You will be self taught as much in residency if not more.

Any fool can be taught anywhere by anyone that 80-year-olds with chest pain need an ekg, CXR, cardiac labs and an admit. Any monkey can learn or teach an LP or chest tube placement or how to juice a 90-yr-old dead guy.

As much as certain God Complex types will tell you you MUST go to their program, and anyone who doesn't, won't be of the highest level, it's BS. The vast, vast majority of what you learn will be based on your own higher order learning, and dependent upon your own neuronal plasticity. Most of what you'll learn will be waking up at 3:30 am and asking yourself, "Why am I worried about that kid I sent home with that splint?" or "How did my attending know to tap that guy who had no meningeal signs?"

The vast majority of it is gut check stuff your brain is going to have to toil over, stretch, twist, turn around and sort out after each shift, while you're asleep and your brain is processing your days cases in dreamtime, during your three years of residency and during your FIRST FIVE YEARS as an attending. There are no shortcuts and where you train is no different.

So, if you match at top-tier Mecca, God-Complex USA, good for you and enjoy the (false) sense of security. But if not, take comfort in that you'll learn all of it, eventually, one way or the other by filling in the avoidable gaps over time like EVERYONE absolutely has to do, including those who think they're shielded by some supposed higher level of training.

Good doctors are good doctors. Effective people are effective. If you commit to being a good (or great) doctor, you'll be a good (or great) doctor. Work hard, learn, read, commit to being the best you can be, and you will be. Where you train matters mainly to the extent it empowers you to be confident in yourself, but don't let where you train DIMINISH that confidence in ANY way.

You will be the type of doctor you make of yourself.



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(I should charge for this s---)

 

[Arcan57]

This thread and the one regarding job choices, made me feel like there is a misconception regarding burnout, skill acquisition, and the relationship of hard work to either. Birdstrike is dead-on in his post above. The idea that you're going to prevent burnout by not working hard in training or during your initial years is non-sense. You'll burnout faster if you never acquire the baseline confidence necessary to survive EM, and false confidence is going to get stripped away quickly during the first years of being an attending. I understand the belief that you can make medicine a secondary or tertiary pursuit in your life and still be a "good" doctor. That may be the case for docs that have been in practice for a long time, but it's not the case for newbies. If your goal is to be a great doc when you fall short you're still likely to be really good. If your goal is to be an average doc, you're going to fall short and be below average. Until we get matrix style neuroimplants or significantly more effective decision support tools, there's no substitute for clinical acumen. And while reading is a necessary part of clinical acumen, it's not sufficient.

 

[AvocadoLover]

This is a great thread. Thanks to all the attendings for their input and advice. I have heard this phrase before and as interview season is wrapping up I find myself believing that it is true. I honestly feel that all of the programs I have interviewed at offer excellent training and I could really see myself being happy there. Am I just naive? What am I missing? If there really are "great" and sub-par training programs how do I tell them apart?

 

[Daiphon]

If there really are "great" and sub-par training programs how do I tell them apart?

Easy.

Great = where you feel most comfortable. You'll enjoy yourself more, resulting in getting more out of clinical experience, finding more time to read/learn non-clinically, and enjoying life.

Sub-par is a bit tougher. Could try looking at metrics (how many fellowships, pass rate on boards, etc).

However, if you focus on the former, you can make a "sub-par" program perfect for what you need.

Cheers!
-d

PS - in all honesty, anything other than the prestigious In-N-Out Residency Program is considered sub-par... so go with your gut regardless. d;-)

 

[dotcb]

Getting back to the original post, I definitely think that all programs will NOT prepare you equally.

That said, compared to other types of residencies, the quality of training in emergency medicine is very high across the board – most residencies are really good.

I think some of the most important things to consider are:

Location - cost of living, proximity to family, spouse happiness, activities you enjoy...
Quality of peers - in EM, and of consultants. On your off-service rotations – is there a good vibe, and are you learning?
Quality of attendings - have they trained at a variety of programs? Is there a diversity of pedigrees? Areas of strength? (US, EMS, CCM, research, tox, etc.) If you decide you want to do something extra – are there mentors available who could help you? Will they help you get a job after residency where you want?
A critical mass of sick patients - residency is the time for mastering this. Being overwhelmed as an attending is what you want to avoid. You can get plenty of practice with fast-track and urgent care later.
A variety of types of patients - county, tertiary, private...
Autonomy - supervision is available when you need it, but is not overbearing.
- do you consult for everything, or do you handle as much as possible yourself? There's a balance - spending 90 minutes on a complex laceration is awesome when you're an intern, but has lost its luster when you're a senior.
Progressive responsibility - Does your job in the ED change as you progress through residency? Are you doing the same amount of scut as a senior compared to when you were an intern? Are years two, three, and four essentially a repeat of each other, or is there value added?
Have previous graduates done things you see yourself doing?
Last but perhaps most important - gestalt/feel

My 2 cents… Would love to hear others - what did you feel really mattered in your residency?

 

[WilcoWorld]

All programs will prepare you equally in the sense that all men [sic] are created equal.

Rather than saying that all programs are the same, because they aren't, I would say that all ACGME-certified programs will present you with the opportunity to make yourself a good Emergency Physician. If programs don't present the residents with that opportunity they loose their accreditation. If you do not seize that opportunity you won't brome a good doc.

I think Diaphon's post above is sage advice. Find where you will flourish, and you have found The Best Program.

 

[Old_Mil]

Different programs will prepare you differently for different environmnets. If you don't train at a gun and knife club you probably aren't as prepared to be an attending in Detroit as someone who does. On the other hand working in a busy community ED has its own challenges based on the sheer amount of weird undifferentiated crap that strolls through your front door. If you work tertiary care a certain percentage of what ends up on your doorstep is prediagnosed by an OSH.

We had ridiculously good peds training and below average trauma training. So you won't see me in Detriot/Chicago/LA anytime soon.

 

[emergentmd]

All programs DEFINITELY will not prepare you equally. ALL programs will give the education/experience to be a good ED doc. It is up to YOU to end up being a good EM doc or not. Some people are made to be good EM docs and some will never be good EM docs no matter where you came from. no different than anything in life or in any other medical fields.

I would recommend to ALL pre med students to go to a inner city/trauma center if at all possible because you may not ever see it again. If you end up your whole career doing community medicine, you will have missed out on some real good EM cases. In 15 yrs in a community setting, I have yet to see a gun shot wound to the chest/head, Blown out face, amputated limbs, etc.

 

[ihearttriangles]

The kind of patient that scares me the most is the "weird" patient. The schizophrenic who complains of snakes in the belly, the 'person living with crack addiction' with chest pain, the altered gomer from the SNF. The patients where you scratch your head and go "hmmmm." Is this total BS or legit? The gsw to the chest, the cardiac arrest, etc... seem significantly easier to handle. You know what is going on, you can flip to a protocol and follow it (if that's your thing). So, I kind of wonder why some people say to focus on seeing the sickest of the sick in residency. Yeah, most people go into EM to see the crashing patient. That is certainly what attracted me. However, it seems like the real art of emergency medicine is deciding who is legit and needs to come in and who is worried well. Now, if only I could figure out which programs are better at fostering this skill...

 

[Arcan57]

It's not a matter of residency so much as a
matter of which charts you pick up. Every chart is a puzzle to solve leading to dispo. The harder the puzzles you solve and the more frequently you have to solve them the better you get. Most people focus on solving the flashy puzzles (MI, Cardiac arrest, level I trauma) and are content to let someone else pick up the 50yo weakness.

 

[deleted547339]

All programs DEFINITELY will not prepare you equally. ALL programs will give the education/experience to be a good ED doc. It is up to YOU to end up being a good EM doc or not. Some people are made to be good EM docs and some will never be good EM docs no matter where you came from. no different than anything in life or in any other medical fields.

I would recommend to ALL pre med students to go to a inner city/trauma center if at all possible because you may not ever see it again. If you end up your whole career doing community medicine, you will have missed out on some real good EM cases. In 15 yrs in a community setting, I have yet to see a gun shot wound to the chest/head, Blown out face, amputated limbs, etc.

Ehhh....I'm getting plenty in my program.....I feel like there's not a ton to learn about them. lol

 

[JimmyB123]

Different programs will prepare you differently for different environmnets. If you don't train at a gun and knife club you probably aren't as prepared to be an attending in Detroit as someone who does. On the other hand working in a busy community ED has its own challenges based on the sheer amount of weird undifferentiated crap that strolls through your front door. If you work tertiary care a certain percentage of what ends up on your doorstep is prediagnosed by an OSH.

We had ridiculously good peds training and below average trauma training. So you won't see me in Detriot/Chicago/LA anytime soon.

Question. A lot of times you hear that working in a busy, county feel ED is difficult because of sheer volume and caseload. But what about working at a tertiary care center where the volume is maybe half of that but the patients are much much more complicated?I have had work experience in both environments (I don't want to give away hospital names so I can stay somewhat anonymous) and I'm kind of curious about something. For example - I was working with an attending at above mentioned "big county ED" that sees >100K visits a year. We started talking about the smaller ED that I worked at previously and she basically said, "Yikes, I could never work there. They see really really sick patients."

So I'm kind of curious..which is the more difficulty environment for an attending?

 

[WilcoWorld]

So I'm kind of curious..which is the more difficulty environment for an attending?

It depends on the attending. Some of us can treat and street like a machine, but get scared by sick patients with >3 preexisting conditions - these types of folks have trouble working in a referral center. Others have no trouble working up a fever and AMS in a transplant patient with an inborn mitochondrial disorder, but get nervous about discharging the worried well without big work ups - these folks would clog up an efficient community ED in no time.

As has been stated above, your training is not complete at the end of residency. The best you can hope for is that you're competent enough to recognize when you've exceeded your abilities. It's not until you've a few years of experience under your belt that you start to get good.

What worked well for me (at least I hope it did) was to train in one type of ED (fast-paced community ED in highly litigious state) then work in the opposite type (overcrowded county ED in relatively medmal-friendly area). I'm now 6 years out and feel pretty comfortable switching gears from moving the meat to chin-stroking chart biopsy mode as needed. While I think my training was great, and I'd highly recommend my old program, I do not think that residency alone could have gotten me to this point.

 

[emergentmd]

Ehhh....I'm getting plenty in my program.....I feel like there's not a ton to learn about them. lol

Not only is the trauma valuable, you get to do MUCH more procedures in a trauma/county environment. I went to med school at a community program where residents fought over procedures with med students. I trained at a county hospital where the first month i was repairing complicated kiddie face lacs where I would never do in my medical school

I proctored a medical student from the one I went to this summer and she never intubated/put in a central line and she was in the middle of her 4th yr. If she was in a county based medical school, she would have done it in her 3rd yr. I pawned off so many procedures to med students in med school just b/c I was sick of them.

 

[mrh682]

It depends on the attending. Some of us can treat and street like a machine, but get scared by sick patients with >3 preexisting conditions - these types of folks have trouble working in a referral center. Others have no trouble working up a fever and AMS in a transplant patient with an inborn mitochondrial disorder, but get nervous about discharging the worried well without big work ups - these folks would clog up an efficient community ED in no time.

As has been stated above, your training is not complete at the end of residency. The best you can hope for is that you're competent enough to recognize when you've exceeded your abilities. It's not until you've a few years of experience under your belt that you start to get good.

What worked well for me (at least I hope it did) was to train in one type of ED (fast-paced community ED in highly litigious state) then work in the opposite type (overcrowded county ED in relatively medmal-friendly area). I'm now 6 years out and feel pretty comfortable switching gears from moving the meat to chin-stroking chart biopsy mode as needed. While I think my training was great, and I'd highly recommend my old program, I do not think that residency alone could have gotten me to this point.

Strongly disagree. As a resident at a high volume (>100k visits per year) academic institution, you can get both acuity, volume and pt complexity/diversity in one program as long as you pick your program appropriately. There are plenty of high volume, high acuity ED's at big name academic medical centers with very complex patients. You need to find the program that has this environment plus penetrating trauma plus a strong community experience.. It exists, I'm in it. While I'm sure my first few years as an attending will augment my residency training, I have no doubt I will graduate from my program w an ability to treat any patient that comes in.
We need to stop perpetuating the myth that county=high vol

 

[mrh682]

Strongly disagree. As a resident at a high volume (>100k visits per year) academic institution, you can get both acuity, volume and pt complexity/diversity in one program as long as you pick your program appropriately. There are plenty of high volume, high acuity ED's at big name academic medical centers with very complex patients. You need to find the program that has this environment plus penetrating trauma plus a strong community experience.. It exists, I'm in it. While I'm sure my first few years as an attending will augment my residency training, I have no doubt I will graduate from my program w an ability to treat any patient that comes in.
We need to stop perpetuating the myth that county=high vol

Whoops didn't finish.. That Only county=high volume. High volume Academic powerhouses have high volume, acuity and complexity.. And diversity if they're inner city hospitals.

 

[WilcoWorld]

Strongly disagree. As a resident at a high volume (>100k visits per year) academic institution, you can get both acuity, volume and pt complexity/diversity in one program as long as you pick your program appropriately. There are plenty of high volume, high acuity ED's at big name academic medical centers with very complex patients. You need to find the program that has this environment plus penetrating trauma plus a strong community experience.. It exists, I'm in it. While I'm sure my first few years as an attending will augment my residency training, I have no doubt I will graduate from my program w an ability to treat any patient that comes in.
We need to stop perpetuating the myth that county=high vol

If I had read my post when I was a resident, I would have disagreed with it as well.

I also think you misunderstood me - I never suggested that only county places = high volume (in fact, I said that efficient community places are where you really learn/need to move the meat).

Oh well, I figured I'd take heat for that post.

 

[Thought Crime Spree]

I'm working on straightening out my ROL and wondering how much I should weigh how similar programs are to my goal practice environment (community EM). I like a bunch of places and my top five include university, community and county type programs and their order is different if I weigh location vs program type vs feel (and I got pretty good vibes from all). Thanks

 

[namethatsmell]

I'm working on straightening out my ROL and wondering how much I should weigh how similar programs are to my goal practice environment (community EM). I like a bunch of places and my top five include university, community and county type programs and their order is different if I weigh location vs program type vs feel (and I got pretty good vibes from all). Thanks

Wherever you think you'll be happiest.

All things being equal, if you want to go community go to which ever shop will let you see/do the most peds/ortho/optho/ENT stuff and procedures.