Longtime SDN member and current EM resident - AMA or don’t. Whatever.

[The Buff OP]

I'll let Gomer Blog explain my feelings towards critical care.

http://gomerblog.com/2016/06/lion-king/

You could of just said no, a-hole. Hahaha.

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[alpinism]

Is the ER busiest during july 4th?

Not sure if its the busiest day but its certainly very busy most years.

Memorial day and Labor day are 2 other days that are usually very busy.

 

[alpinism]

1.) Will you use a scribe once you finish residency?

2.) How many patients does a resident typically see in a 8-hour (or 12-hour) shift?

3.) Do you think ERs will see the same volume of patients in 10 years as they are now? (for reference, the ER I work in sees just under 200 patients a day in an area where primary care is pretty garbage)

1) Probably not. I'm not planning on working in a community ER after residency.

2) Depends on the year. Interns usually see 1 around patient per hour (8 per shift) and Senior Residents can see up to 2 patients per hour (16 per shift).

3) Hard to say. As long as ER docs are forced to see every patient that walks through the door there won't be any shortage of patients for the next 10 years.

 

[alpinism]

In your opinion, what are the right reasons to join EM? The wrong reasons? Anything you learned in practice that you didn't know before you committed?

Great question. I'd say the right reasons would be things like you enjoy seeing a wide variety of patients, you like the diagnostic process, you like doing procedures, and you like dealing with stressful life and death situations. The wrong reasons would be things like doing it because you think its an easy residency or because you think its a lifestyle specialty. Sadly there are a quite a few EM residents out there today who if you asked them "why did you choose EM" their honest answer would be because its only a 3 year residency, the hours are good, you don't have to take call, and its easy to find a job in most cities. Not surprisingly many end up burnt out after only a few years of working as an attending. The biggest surprise was probably finding out how much time an average EM doc spends keeping the department running and managing patient flow instead of providing actual patient care.

Does the EM physician work irregular shifts (changing from night and day) forever? Or is it more lenient as you get older?

Not always. There are jobs available out there where you can work just day shifts. These are usually only available to older physicians who have put their time in and have been working for 10+ years. At the same it comes at a cost and you usually end up making less money than your partners. Another option would be to get out of clinical medicine altogether and do academic or administrative work.

In a tertiary care center, what is the role of the EM physician exactly? How does it differ from the on-call trauma surgeon/general surgeon?
As in, is the EM still in charge of stabilizing the patient while the trauma/general surgeon waits?

Depends on the hospital. At some places the EM doc does everything while the patient is still in the ER. At other places the EM doc just manages the airway and the trauma team does everything else while the patient is still in the ER. And at other places the EM doc does nothing and the trauma team does everything while the patient is still in the ER.

Do you spend all of your time in the ER, or some parts of it elsewhere, such as the ICU?

Nope. We rotate through the medical ICU, trauma ICU, and pediatric ICU plus do off service rotations like Orthopedics, Gynecology, and Anesthesia.

What sort of international work? Docs without borders?

Yep. I've got a diploma in Tropical Medicine and plan on using it after residency.

 

[ZorkDork1]

Thanks for the reply!

Depends on the hospital. At some places the EM doc does everything while the patient is still in the ER. At other places the EM doc just manages the airway and the trauma team does everything else while the patient is still in the ER. And at other places the EM doc does nothing and the trauma team does everything while the patient is still in the ER.

.

This part confused me a little bit. So... the ER doc isn't part of the emergency process at all? Doesn't sound very fulfilling. What's your take on this?


I also read in one of your earlier posts that you see one patient an hour. Is that true? I'd imagine you'd be swamped with waaay more patients than that. I could be wrong though.


And the ICU question was meant to be POST-residency. As an attending ER physician, do you still rotate?


And finally, how would you rate the happiness of ER docs in general versus other fields? Higher, average, lower? I know this answer will be anecdotal, I was just curious.

Thanks!

 

[alpinism]

This part confused me a little bit. So... the ER doc isn't part of the emergency process at all? Doesn't sound very fulfilling. What's your take on this?

At some trauma centers the trauma bay is separate from the main ER (Cook County for example) and at others the trauma bay is in a whole other building (University of Maryland for example). At these places all traumas are run by trauma surgery and not emergency medicine. EM residents do rotate through trauma and spend time on the trauma team, but they are supervised by trauma surgeons and not EM physicians.

Most of these places have very strong surgery programs that have traditionally dominated the hospital. Remember, EM is a relatively new specialty and most EM departments are less than 30 years old. On the other hand many surgery departments have been around for over 100 years. Prior to EM, surgery usually cared for all trauma patients in the ER since they were the only specialty that received any trauma training during residency.

IMO all emergency patients should be cared for by a board certified EM physician while in the ER. This includes patients suffering from traumatic injuries. Once outside the ER trauma surgeons can then take over care for patients. Obviously I'm biased but EM is the only specialty that is qualified to manage the entire trauma patient and any medical conditions that the patient might have in addition to their injuries. Surgeons are not qualified to manage the airway or any medical conditions that the patient might have and as a result they must have an anesthesiologist with them if there is no EM physician available.

I also read in one of your earlier posts that you see one patient an hour. Is that true? I'd imagine you'd be swamped with waaay more patients than that. I could be wrong though.

Interns usually see around 1 patient per hour while senior residents usually see around 2 patients per hour. We're still learning EM so it takes us longer than an experienced EM physician who's been doing the job for 10+ years. On the other hand some really fast attendings can see up to 4 patients per hour.

And the ICU question was meant to be POST-residency. As an attending ER physician, do you still rotate?

Ahh gotcha. Nope. EM physicians don't do any more rotations after residency.

And finally, how would you rate the happiness of ER docs in general versus other fields? Higher, average, lower? I know this answer will be anecdotal, I was just curious.

Hmm I'd say about average. Probably above surgeons but below radiologists.

 

[ZorkDork1]

Interns usually see around 1 patient per hour while senior residents usually see around 2 patients per hour. We're still learning EM so it takes us longer than an experienced EM physician who's been doing the job for 10+ years. On the other hand some really fast attendings can see up to 4 patients per hour.

Hmm, so a typical ER doc, on a 8 hour shift, seems 8-16 patients? Do you ever go an entire shift without dealing with an emergency? How often does that happen?


Aside from an ER doc and trauma surgeon, what would you say are the next few specialties that deal the MOST with emergency-like situations? Or even spend large amounts of time in the ER?
Ortho for broken bones? Neuro for head injuries?
I read in an earlier post of yours that you weren't too attracted to surgery because they tend to become really specialized (a shoulder guy for example, or one type of tumor guy). But there's gotta be some surgeons who are geared towards emergency, right? Do they consciously choose this route, or whenever the shoulder guy is on call, he also has to come and fix broken bones from an accident? I hope this question wasn't too confusing.

Thanks! I'm really enjoying all of the information you're providing.

 

[avgn]

@ZorkDork1 Most trauma surgeons are doing gen surg procedures most hours of the day when there are no trauma cases to be had. You can bet they also wind up specializing to a certain extent. Trauma doesn't mean you only do emergency cases. I guess you could be at Cook or Kings where there's so much penetrating that you'll have your hands full most of the time but it's not what the name "trauma surgeon" suggests most of the time from what I understand.

 

[alpinism]

Hmm, so a typical ER doc, on a 8 hour shift, seems 8-16 patients? Do you ever go an entire shift without dealing with an emergency? How often does that happen?

Depending on your definition of an emergency, yeah it happens about 3-4 times per year. That being said, I'm at one of the busiest ERs in one of the most violent cities in the country. At most community ERs its far more common and probably happens at least 3-4 times per month.

Aside from an ER doc and trauma surgeon, what would you say are the next few specialties that deal the MOST with emergency-like situations? Or even spend large amounts of time in the ER?
Ortho for broken bones? Neuro for head injuries?

Off the top of my head I'd say the most common specialties that deal with emergencies on a regular basis would be Neurology (strokes), Neurosurgery (head injuries), Psychiatry (suicide attempts), Cardiology (heart attacks), Gastroenterology (GI bleeds), and Orthopedics (broken bones).

I read in an earlier post of yours that you weren't too attracted to surgery because they tend to become really specialized (a shoulder guy for example, or one type of tumor guy). But there's gotta be some surgeons who are geared towards emergency, right? Do they consciously choose this route, or whenever the shoulder guy is on call, he also has to come and fix broken bones from an accident? I hope this question wasn't too confusing.

I get what you're trying to ask, however for the most part that job doesn't exist in the US today. With the exception of a few very busy trauma centers there just isn't enough surgical volume to support a full time emergency surgeon. Using orthopedics as an example, most fractures are straightforward and easily handled by an ER doc. For those few fractures that might need an operation, the orthopedic surgeon is than called into the ER. After seeing the patient, the orthopedic surgeon then decides if they need an operation or not. Oftentimes its hard to tell immediately after the injury if they'll need an operation, so the orthopedic surgeon will wait and see if the fracture heals on its own before making a final decision. Even if they do decide right away that they will need an operation, they will usually wait 1-2 weeks until after the soft tissue swelling has gone down to perform the operation. As a result its is very rare for a orthopedic surgeon to have to come in the middle of the night to do an emergency surgery. If all you did was emergency surgeries you'd probably only end up operating maybe once a week at the most.

 

[iforget2]

When you say you work an 8 hour shift i.e. 7-3, do you get paid for the lunch hour? Or how does the lunch hour work?

 

[The Buff OP]

@alpinism
Have you ever seen these YouTube channels?
https://www.youtube.com/user/theedexitvideo
https://www.youtube.com/user/lmellick

 

[avgn]

When you say you work an 8 hour shift i.e. 7-3, do you get paid for the lunch hour? Or how does the lunch hour work?

10/10 asking the important questions here

 

[iforget2]

10/10 asking the important questions here

Haha yea I work 8-5 at my job but it only counts as 8 hours bc we don't get paid lunch so I was wondering if it's like this elsewhere

 

[Cyberdyne 101]

When you say you work an 8 hour shift i.e. 7-3, do you get paid for the lunch hour? Or how does the lunch hour work?

I'm pretty sure they get a salary.

 

[alpinism]

When you say you work an 8 hour shift i.e. 7-3, do you get paid for the lunch hour? Or how does the lunch hour work?

We don't get a lunch break

But seriously, when your in the ER you're usually busy working all shift. Most people eat before and after shifts and some also eat a small snack in between seeing patients. For 8 hours its really not a problem and your body gets used to it after a few shifts.

 

[Cyberdyne 101]

In another thread, you mentioned that the amount of hands on experience during clinical rotations is diminishing. Do you expect this trend to reverse at all?

Also, are there any specific changes that you'd like to see implemented in medical education?

 

[alpinism]

@alpinism
Have you ever seen these YouTube channels?
https://www.youtube.com/user/theedexitvideo
https://www.youtube.com/user/lmellick

I have!

Mellick's videos are awesome. Used to watch them all the time as a med student.

Vanderbilt also has some cool EM videos on youtube: https://www.youtube.com/user/VanderbiltEM/videos

 

[alpinism]

Speaking of EM videos Einstein has a great overview of EM including a Q&A session with their residency director.

 

[Cyberdyne 101]

More like lol, hour lunch break, that's cute

Do you even get 10 minutes?

 

[ZorkDork1]

Does the job ever get monotonous? How often do you perceive emergency medicine evolving with technological advances compared to say, cancer or surgery?

 

[alpinism]

In another thread, you mentioned that the amount of hands on experience during clinical rotations is diminishing. Do you expect this trend to reverse at all?

Probably not. If anything it will continue to get worse over the next few years.

The problem is that there is no real incentive to provide hands on experience to med students nowadays. Not only that but it slows down the hospital so they end up losing money compared to just letting the resident or attending quickly do the procedure. Back in the day you were required to know how to do basic medical procedures before graduating because many doctors didn't do a residency and just became general practitioners. Nowadays since 99% of students go on to do a residency they just pass the buck and leave it up to residencies to teach basic medical procedures.

Also, are there any specific changes that you'd like to see implemented in medical education?

Absolutely yes. I could honestly write a whole book about the things I'd like to see changed.

The fact of the matter is that modern medical education is very inefficient and redundant and as a result you waste tons of time learning things that either A) you already learned in college as an undergrad or B) you don't need to know unless you become a specialist. Once and a while someone tosses around the idea of making the 1st 2 years of medical school prerequisites and then replacing the MCAT with the USMLE. While I agree with the general idea, I think that specific plan would be a little too extreme and hurt the quality of medical education. IMO I think the best option would be to make the 1st year courses prerequisites and then convert med school to 3 years. In this scenario you would still essentially take all the same courses, but you would cut out a whole year of med school and med school tuition. At the same time you would keep the entire USMLE system in place and still apply to residency during your last year of med school.

Ideally the new med school system would look like this:

-Premedical students would still attend undergrad anywhere they choose and major in whatever interests them so you'd still get a broad based liberal arts education. The new prerequisites would be 1 year of general biology, 1 year of general chemistry, 1 year of biochemistry, 1 year of physiology, 1 year of anatomy, and 1 year of neuroscience. This would come out to 12 semesters of courses which is only 4 more than what is normally required today. Organic chemistry and Physics are for the most part a waste of time and unnecessary to practice medicine so they would not be required anymore. At the same time, 1st year courses such as embryology and genetics are also largely too sub specialized for most doctors and unnecessary to practice medicine. The important parts of these courses would be kept and combined with the above prerequisites.

-Medical school would consist of 1 classroom year and 2 clinical years. This is already occurring at some US schools such as Duke and Vandy, however they include a whole year for research which is why they are still 4 year schools. In the new system you would actually have less information to learn 1st year since you already took the 1st year classes in undergrad. Essentially you'd just be taking the 2nd year courses as a 1st year instead. Med schools would still use the organ system based model to teach courses during the 1st year. Instead of doing PBL you would do simulated cases in a sim center to get practical experience and learn to do basic procedures. The 1st clinical year would stay the same except you'd only have one lecture day per week and would be required to complete a checklist of basic medical procedures before finishing each rotation. The second clinical year would consist of a couple required rotations and the rest would be elective rotations in whatever specialty you're interested in learning more about before you graduate med school. Each school would also have mandatory time off during interview season so that you don't have to leave rotations to interview.


Benefits of the new system:

-Cut out unnecessary and useless undergrad prereqs
-Cut out unnecessary and useless med school courses
-Don't need to change the current application process
-Don't need to change the current USMLE exam schedule
-Don't need to change the current residency match timeline
-Makes medical education 1 year shorter (minimum of 6 years after undergrad instead of 7 years)
-Makes medical education more affordable for everyone (students graduate with less debt after finishing med school)
-Makes it easier for low SES and minority students to enroll in medical school (as a result of the lower cost and time commitment)
-Makes medical school less stressful and time consuming since you spread out the 1st year courses (less time spend studying all night during 1st year)

 

[The Buff OP]

I have!

Mellick's videos are awesome. Used to watch them all the time as a med student.

Vanderbilt also has some cool EM videos on youtube: https://www.youtube.com/user/VanderbiltEM/videos

Thanks, I'll check it out.

 

[Psai]

Probably not. If anything it will continue to get worse over the next few years.

The problem is that there is no real incentive to provide hands on experience to med students nowadays. Not only that but it slows down the hospital so they end up losing money compared to just letting the resident or attending quickly do the procedure. Back in the day you were required to know how to do basic medical procedures before graduating because many doctors didn't do a residency and just became general practitioners. Nowadays since 99% of students go on to do a residency they just pass the buck and leave it up to residencies to teach basic medical procedures.



Absolutely yes. I could honestly write a whole book about the things I'd like to see changed.

The fact of the matter is that modern medical education is very inefficient and redundant and as a result you waste tons of time learning things that either A) you already learned in college as an undergrad or B) you don't need to know unless you become a specialist. Once and a while someone tosses around the idea of making the 1st 2 years of medical school prerequisites and then replacing the MCAT with the USMLE. While I agree with the general idea, I think that specific plan would be a little too extreme and hurt the quality of medical education. IMO I think the best option would be to make the 1st year courses prerequisites and then convert med school to 3 years. In this scenario you would still essentially take all the same courses, but you would cut out a whole year of med school and med school tuition. At the same time you would keep the entire USMLE system in place and still apply to residency during your last year of med school.

Ideally the new med school system would look like this:

-Premedical students would still attend undergrad anywhere they choose and major in whatever interests them so you'd still get a broad based liberal arts education. The new prerequisites would be 1 year of general biology, 1 year of general chemistry, 1 year of biochemistry, 1 year of physiology, 1 year of anatomy, and 1 year of neuroscience. This would come out to 12 semesters of courses which is only 4 more than what is normally required today. Organic chemistry and Physics are for the most part a waste of time and unnecessary to practice medicine so they would not be required anymore. At the same time, 1st year courses such as embryology and genetics are also largely too sub specialized for most doctors and unnecessary to practice medicine. The important parts of these courses would be kept and combined with the above prerequisites.

-Medical school would consist of 1 classroom year and 2 clinical years. This is already occurring at some US schools such as Duke and Vandy, however they include a whole year for research which is why they are still 4 year schools. In the new system you would actually have less information to learn 1st year since you already took the 1st year classes in undergrad. Essentially you'd just be taking the 2nd year courses as a 1st year instead. Med schools would still use the organ system based model to teach courses during the 1st year. Instead of doing PBL you would do simulated cases in a sim center to get practical experience and learn to do basic procedures. The 1st clinical year would stay the same except you'd only have one lecture day per week and would be required to complete a checklist of basic medical procedures before finishing each rotation. The second clinical year would consist of a couple required rotations and the rest would be elective rotations in whatever specialty you're interested in learning more about before you graduate med school. Each school would also have mandatory time off during interview season so that you don't have to leave rotations to interview.


Benefits of the new system:

-Cut out unnecessary and useless undergrad prereqs
-Cut out unnecessary and useless med school courses
-Don't need to change the current application process
-Don't need to change the current USMLE exam schedule
-Don't need to change the current residency match timeline
-Makes medical education 1 year shorter (minimum of 6 years after undergrad instead of 7 years)
-Makes medical education more affordable for everyone (students graduate with less debt after finishing med school)
-Makes it easier for low SES and minority students to enroll in medical school (as a result of the lower cost and time commitment)
-Makes medical school less stressful and time consuming since you spread out the 1st year courses (less time spend studying all night during 1st year)

I agree with the general point about preclinical but I think that undergrad anatomy doesn't even come close to replacing medical school anatomy. Circulation is basically electrical circuits with the same general principles. Understanding fluid dynamics is very important as well. Other important topics of value include random walk, diffusion, applied statistics in thermodynamics. You don't need to know magnetism, harmonic oscillators or quantum mechanics. Organic chemistry has value in teaching you how to think through problems, understand molecular interactions, knowing the basic forms of sidechains, oxidation/reduction, etc. You don't need to know how to synthesize compounds with memorization of the reactants and reaction conditions but understanding the basics is important. I've noticed that people with a physical science background think through problems different than those with a biological science background.

 

[akwho]

I agree with the general point about preclinical but I think that undergrad anatomy doesn't even come close to replacing medical school anatomy. Circulation is basically electrical circuits with the same general principles. Understanding fluid dynamics is very important as well. Other important topics of value include random walk, diffusion, applied statistics in thermodynamics. You don't need to know magnetism, harmonic oscillators or quantum mechanics. Organic chemistry has value in teaching you how to think through problems, understand molecular interactions, knowing the basic forms of sidechains, oxidation/reduction, etc. You don't need to know how to synthesize compounds with memorization of the reactants and reaction conditions but understanding the basics is important. I've noticed that people with a physical science background think through problems different than those with a biological science background.

Echo Psai. Physics is an incredibly important class for doctors. Vent settings, hemodialysis diffusion gradients, fracture fixation, and MRI/CT applications just off the top of my head.

 

[alpinism]

Do you even get 10 minutes?

Depends on how busy you are during your shift.

Unless its really crazy there usually is enough time to take a couple 10min breaks.

 

[alpinism]

Does the job ever get monotonous? How often do you perceive emergency medicine evolving with technological advances compared to say, cancer or surgery?

Yeah sometimes. Especially when you're seeing the same elderly male with chest pain or middle aged female with abdominal pain day after day. That being said every day is completely different and you never know what will walk through the door next. Overall its much less monotonous compared to working in clinic or on the wards.

 

[dinocorn]

Hi, I'm a longtime lurker and really appreciate you doing this. What factors went into your rank list for the match? And unrelated, but how does ED compensation work for you when you have uninsured patients? Thank you!

 

[Psai]

Hi, I'm a longtime lurker and really appreciate you doing this. What factors went into your rank list for the match? And unrelated, but how does ED compensation work for you when you have uninsured patients? Thank you!

You work for free because the federal government mandates that you have to evaluate for an emergency due to emtala

 

[avgn]

You work for free because the federal government mandates that you have to evaluate for an emergency due to emtala

Yeah but the beauty as an ED doc is that you're salaried or per diem by the hour and don't have to deal with that. Hospital takes care of it by balance billing where they can and most EDs still end up as a revenue generator for their hospitals unless it's one of the outliers where the majority of visitors are uninsured.

 

[alpinism]

I agree with the general point about preclinical but I think that undergrad anatomy doesn't even come close to replacing medical school anatomy. Circulation is basically electrical circuits with the same general principles. Understanding fluid dynamics is very important as well. Other important topics of value include random walk, diffusion, applied statistics in thermodynamics. You don't need to know magnetism, harmonic oscillators or quantum mechanics. Organic chemistry has value in teaching you how to think through problems, understand molecular interactions, knowing the basic forms of sidechains, oxidation/reduction, etc. You don't need to know how to synthesize compounds with memorization of the reactants and reaction conditions but understanding the basics is important. I've noticed that people with a physical science background think through problems different than those with a biological science background.

So yeah ideally the 1st year courses taken in undergrad (biochemistry, physiology, anatomy, and neuroscience) would still cover the same information in the same depth. They would just get spread out over the course of 1 year instead of 1 semester like in med school. I would absolutely not support any plan that replaces them with watered down undergrad courses. I get your points about physics and organic chemistry but IMO they are both used so infrequently that its not worth making them a hard and fast requirement. In comparison, biology and general chemistry are both used literally everyday for every patient. In addition, what little physics and organic chemistry you do need to know can easily be learned as part of a physiology and biochemistry course.

 

[Psai]

So yeah ideally the 1st year courses taken in undergrad (biochemistry, physiology, anatomy, and neuroscience) would still cover the same information in the same depth. They would just get spread out over the course of 1 year instead of 1 semester like in med school. I would absolutely not support any plan that replaces them with watered down undergrad courses. I get your points about physics and organic chemistry but IMO they are both used so infrequently that its not worth making them a hard and fast requirement. In comparison, biology and general chemistry are both used literally everyday for every patient. In addition, what little physics and organic chemistry you do need to know can easily be learned as part of a physiology and biochemistry course.

I just think that medical education was terrible before the flexner report and that we shouldn't dumb things down back to that level just to get people through a little faster. If we just breeze through or skip prereqs with fundamental knowledge on the level of an np or a chiropractor, there's no point in having medical doctors. Who will advance the science and practice of medicine? This is moot of course if we end up practicing protocolized factory medicine like the government-insurance company-hospital administration-malpractice law complex wants us to

Sorry this is totally off topic from your ama

 

[Wolfpack93]

Do/will press ganey scores affect your pay at all?

 

[alpinism]

Hi, I'm a longtime lurker and really appreciate you doing this. What factors went into your rank list for the match? And unrelated, but how does ED compensation work for you when you have uninsured patients? Thank you!

1. Pathology

- Do they have a high volume and acuity of patients with lots of medical and trauma resuscitations?

2. Curriculum

- Do they focus on learning to take care of sick patients from day one instead of having graduated responsibility?

3. Department

- Do they have a strong well established department within the hospital that has already fought and won all the turf battles?

4. Residents

- Do they have passionate and hardworking residents who you would love to grab a beer with after working an overnight shift in the ER?


Based on the above it was pretty easy to narrow down my application and rank list. My ideal EM program was basically 3 years, inner city hospital, over 100K patients per year, see sick patients during every shift, don't have to fight for procedures, and awesome fun loving residents. Ultimately I choose to look at mainly the bread and butter of EM programs instead of focusing on the little things like number of shifts per month, shift length, electives, and fellowships. In the end it didn’t really come down to that anyway since there are only a small handful of programs that even meet the criteria that I used to rank programs. Hell if you look at my previous posts and do your own research you could probably figure out where I am or at least narrow it down to a few programs.

 

[alpinism]

Yeah but the beauty as an ED doc is that you're salaried or per diem by the hour and don't have to deal with that. Hospital takes care of it by balance billing where they can and most EDs still end up as a revenue generator for their hospitals unless it's one of the outliers where the majority of visitors are uninsured.

Exactly. Most EM docs are salaried unless you own your own urgent care center or freestanding emergency department.

 

[alpinism]

I just think that medical education was terrible before the flexner report and that we shouldn't dumb things down back to that level just to get people through a little faster. If we just breeze through or skip prereqs with fundamental knowledge on the level of an np or a chiropractor, there's no point in having medical doctors. Who will advance the science and practice of medicine? This is moot of course if we end up practicing protocolized factory medicine like the government-insurance company-hospital administration-malpractice law complex wants us to

Sorry this is totally off topic from your ama

No worries. Every medical doctor should have a strong science background its just a matter of how many and which courses should be required.

 

[ZorkDork1]

I'm curious... Why don't some ER docs do only night shifts, and some do only morning shifts?
I feel like switching between the two is what's problematic, having to constantly adjust sleep schedules. But I could see myself getting into the graveyard shift rhythm


Sent from my iPhone using SDN mobile

 

[Cinclus]

I'm curious... Why don't some ER docs do only night shifts, and some do only morning shifts?
I feel like switching between the two is what's problematic, having to constantly adjust sleep schedules. But I could see myself getting into the graveyard shift rhythm


Sent from my iPhone using SDN mobile

It isn't super uncommon to have dedicated nocturnists, because most people prefer day shifts and welcome those who want to take a bunch of nights so they don't have to work as many. Since most people prefer working days, it would be extremely difficult to find a job allowing you to only work day shifts.

 

[alpinism]

Do/will press ganey scores affect your pay at all?

For residents they don't affect your pay. For attendings it depends on your contract with the hospital.

 

[Wolfpack93]

For residents they don't affect your pay. For attendings it depends on your contract with the hospital.

Sorry, can you explain this a little more? Do certain provider's contracts make it so these scores don't carry much weight or is it more hospital specific?

 

[alpinism]

I'm curious... Why don't some ER docs do only night shifts, and some do only morning shifts?
I feel like switching between the two is what's problematic, having to constantly adjust sleep schedules. But I could see myself getting into the graveyard shift rhythm


Sent from my iPhone using SDN mobile

There are some younger single EM docs who work just nights for a few years after residency. They usually get paid more for night shifts and use the extra money to pay off loans or buy a new car or house. Eventually though most end up getting married or having kids and decide to switch back to days but there are some who continue to work just nights. At the same time there are also some older married EM docs who work just days towards the end of their career. They usually get paid less and are willing to take a pay cut in order to spend more time with their family and friends. In any case I wouldn't go into EM expecting to be able to work just nights or days since most hospitals will make you work both shifts.

 

[The Buff OP]

What is a must have for you (carry on)?
Like this guy. Edit: Bro, they deleted the video. What the hell.
Anyways he has a backpack with an et tube ready (bougie in it too), meds, and laryngoscope. From what they showed in that clip, pretty sure he had other stuff too.

Do you think doing an EM residency at a high volume city makes the best EM docs? For example, Baltimore, Los Angeles, Orlando, New York, and Boston.

 

[Tenk]

Sorry, can you explain this a little more? Do certain provider's contracts make it so these scores don't carry much weight or is it more hospital specific?

Most hospitals don't tie in press ganey scores to physician reimbursement but some do.

Many hospitals will tie physician reimbursement into things like charting, core measures and other metrics. Patient satisfaction is not nearly as common as these other metrics as these other metrics are much more important for reimbursement purposes. Obviously this may change over the next several years.

Overall you don't have anything to worry about if you work hard, are nice to everyone, and dispense lots and lots of dilaudid.

 

[Gurby]

What is a must have for you (carry on)?
Like this guy.

Do you think doing an EM residency at a high volume city makes the best EM docs? For example, Baltimore, Los Angeles, Orlando, New York, and Boston.

Thanks for the reminder that I need to finish watching that series.

Somewhat related picture that I enjoy:

 

[Psai]

What is a must have for you (carry on)?
Like this guy.

Do you think doing an EM residency at a high volume city makes the best EM docs? For example, Baltimore, Los Angeles, Orlando, New York, and Boston.

A strong em department that controls things and fought the battles already, don't have to compete with consultants, diverse pathology from a large catchment area

 

[alpinism]

What is a must have for you (carry on)?
Like this guy. Edit: Bro, they deleted the video. What the hell.
Anyways he has a backpack with an et tube ready (bogie in it too), meds, and laryngoscope. From what they showed in that clip, pretty sure he had other stuff too.

That's the guy from NYMed right?

Yeah that guy needs to chill the f**k out. Most of my patients are like that if not worse and I’d go crazy if I was that hyperactive all shift. Not to mention it would be super annoying during resuscitations. Hopefully he’ll learn to calm down by the time he’s done with residency.

Not sure why he’s carrying around all that stuff either. There really is no reason to carry around intubation equipment or meds since there should be fully stocked crash carts in every resuscitation bay. In addition they should all be set up and ready to go for the next patient.

As far as stuff I carry with me during shifts:

stethoscope
trauma shears
eye protection
couple pens
pair of gloves
roll of tape
flashlight
scalpel blade
tourniquet
angiocath

Do you think doing an EM residency at a high volume city makes the best EM docs? For example, Baltimore, Los Angeles, Orlando, New York, and Boston.

Definitely. I'd go even further and say that doing EM residency in a high volume crime ridden drug infested city makes the best EM docs. You want to see as many patients as possible during residency but if you're mostly seeing only minor BS complaints you're never going to get comfortable taking care of sick patients.

 

[alpinism]

Here's how EM docs should act during resuscitations:

 

[PS2020]

You mentioned Kings County as one of your rotation sites. Can you comment more on the top programs in NYC? My impression of EM residencies was that big name academic hospitals offer inferior training to community and county places. So does that mean the list would look something like this?

Kings county
Lincoln
Elmhurst
Jacobi
NYU/Bellevue
NYP-Columbia&Cornell
Mount Sinai

Are there top name brand programs that are also top EM programs? Like Hopkins in Baltimore is in a rough area, but so is UMD. Which one would have a better rep? Similarly, I hear BU gets most of the good emegency stuff in Boston, while the Harvard hospitals (BID, BWH, MGH) have to fight among each other for patients. Which Boston residency would be considered the better one in terms of pathology, pt volume, ED politics/strengths, etc? Obviously training at Beth Israel Deaconness in most other fields is a lot more impressive than training at BU. However Ive heard thats not true for EM.

Does coming from a better regarded residency (within the EM community) mean that you have more negotiation power/levarage to get a higher salary? If so, how much leverage? Is it enough to make a difference between getting a well paid job in a saturated market and not?

Can you comment more on the 3 vs 4 year programs? It appears that the "name brand" places like NYU, NYP, Penn, etc. are exclusively 4 years. Its obvious that having an extra year of training is beneficial, but the question is whether not having that year hinders your job prospects coming out of residency. Is that one extra year really worth a years worth of attending salary? I imagine if a grad from a 4 year program comes out making an extra 40k a year they will break even in a few years making it worth it academically and financially.

Thanks for this very informative AMA!

 

[The Buff OP]

That's the guy from NYMed right?

Yeah that guy needs to chill the f**k out. Most of my patients are like that if not worse and I’d go crazy if I was that hyperactive all shift. Not to mention it would be super annoying during resuscitations. Hopefully he’ll learn to calm down by the time he’s done with residency.

Not sure why he’s carrying around all that stuff either. There really is no reason to carry around intubation equipment or meds since there should be fully stocked crash carts in every resuscitation bay. In addition they should all be set up and ready to go for the next patient.

As far as stuff I carry with me during shifts:

stethoscope
trauma shears
eye protection
couple pens
pair of gloves
roll of tape
flashlight
scalpel blade
tourniquet
angiocath



Definitely. I'd go even further and say that doing EM residency in a high volume crime ridden drug infested city makes the best EM docs. You want to see as many patients as possible during residency but if you're mostly seeing only minor BS complaints you're never going to get comfortable taking care of sick patients.

Funny that you mention that he needs to slow down. He is an attending now.
https://gyazo.com/9b6b10a8d681dc88939b8325b7db2487 A review from Healthgrades.com

I think so as well. I read that at Mayo EM residency they mostly saw blunt trauma and not that much of penetrating traumas. I think it was here on EM forums.

When you were a medic what did you carry? No lie this guy at my old job had freaking Batman belt on with tons of ****. I only carried pens, notepad, trauma shears, cellphone, radio clip, snacks (lol you know why), extra gloves, and sometimes a pen light.

 

[The Buff OP]

Here's how EM docs should act during resuscitations:

I need to watch this one again.

 

[timetraveling]

@alpinism

Important questions first:
Hillary or Trump? Or, Gary Johnson?
Chewy or crispy bacon?
Spicy chicken or hamburger?

Less important questions:
Can I simultaneously have a life and work at an academic hospital?
For clarification, did you go to US med school then go over to South Africa? Or...what? If first scenario, what drove the decision to not stay here?
How often do you work with ENT, Plastics, and obv. NSG and Ortho? My goal as a doc is to help the people hurting the most in the ER, whether as an EM Phys or not.
What could you tell me about ICU work (I guess it's critical care/pulm?)?
What ways has EM changed you--in regards to diet, social life, the ways you look at death, et cetera?

Thanks