Worst EM Off-Service Rotation Poll

[waterski232002]

I'm stuck on Trauma Surgery right now pulling q3-q4 call and I've got lots of time on my hands. What do you guys think is the most low yield EM off service rotation? You know.... the one where you're scutted out the most, and you're not learning jack $hit!

I messed up the other thread... this one actually has the poll.

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[po' boy]

one vote for VA medicine floors. i hate that friggin hospital.

was coding a guy last week and called out for intubation drugs, ANY intubation drugs. was told by one of the nuruses, "you'll have to put an order in for that."

 

[GeneralVeers]

It depends on the hospital. I think universally Medicine Wards have the lowest yield for most residents everywhere.

At King/Drew our in-house pediatrics blows. They do a septic workup and/or CT scan on every kid who comes in regardless of complaint. At least we rotate at L.A. Children's ER now, which is an amazing rotation.

 

[pushinepi2]

Is the worst.

I have had similar experiences as a paramedic student, medical student, and EM intern. At least I can be occasionally useful when patients are in need of an intravenous line, an EKG read, or an assessment of their asthma. Yay. Plus, I love the daily anti-em rants. That makes the entire rotation worthwhile.

Excuses for not delivering a baby:
"You don't really know this patient.."
"She has the potential to be difficult.."
"She's preterm.."
"She has a vagina..."
"You EM guys would benefit from a more normal and controlled delivery.."


-PuSh

 

[Apollyon]

It's hard for me to say, because my peds, OB, anesthesia, surgery, and PICU rotations REALLY sucked (surgery, OB, and PICU were ****, for various reasons, and anesthesia and peds were more just duds), and the MICU was only marginal - at Duke, the MICU is essentially just another medicine floor for 3/4 of the patients. The difficulty is that the sucky rotations were changed or eliminated, mostly, so it's not the same now.

 

[GeneralVeers]

Our PD is trying to get rid of medicine wards entirely, and have us do two months of MICU instead.

We'll see what Internal Medicine says about that...

 

[bulgethetwine]

Our PD is trying to get rid of medicine wards entirely, and have us do two months of MICU instead.

We'll see what Internal Medicine says about that...

This is GREAT! I've been running this poll in my own head for a year now!

I think that an emergency medicine residency should just as well be considered EM/Critical Care -- so down with ANY floor month of CT surg, Medicine, General Peds, General Cardiac, etc. and replace with more critical care months. I know, I know, the politics of it would never work because the other services need man power (or scut power more like it), the extra call would suck for us personally (many units are q3), someone inevitably will say, "Oh, you need to learn how things WORK on the floor before you charge into the unit", and someone else will chime in with "But it's great to see what happens to the patients once they leave the ED!" ....

(To which a cynic, say, oh, ME, might say "Oh yeah? Does it really add to my education to know what Day 3 of post-STEMI care should be"?

Ok, ok, I'll admit that for every crappy rotation, scut work rotation, or just plain useless rotation to our specialty, there is inevitably ONE nugget of knowledge, or you make one relationship that will be useful a year from now when you're trying to admit to a given service. But the standard question to ask should be --

"Notwithstanding that I will learn SOMETHING on this month of [insert rotation], is there another rotation that would be higher yield and/or more relevant to my specialty given that I only have 3-4 years to be a resident?"

 

[bulgethetwine]

It's hard for me to say, because my peds, OB, anesthesia, surgery, and PICU rotations REALLY sucked (surgery, OB, and PICU were ****, for various reasons, and anesthesia and peds were more just duds), and the MICU was only marginal - at Duke, the MICU is essentially just another medicine floor for 3/4 of the patients. The difficulty is that the sucky rotations were changed or eliminated, mostly, so it's not the same now.

I actually heard that at Duke OB functions in a pretty novel way for emergency medicine residents -- that they effectively staff the OB triage and so get to deal with true OB undifferentiated complaints and emergencies, as well as get to do a set number of deliveries on the normal ward as time between triage flow permits. Seems like a novel way to satisfy an OB service that needs manpower, an ED program that needs to have obstetric rotation time, and ED residents who invariably don't want to be dealing with floor OB but need exposure to OB issues.

 

[southerndoc]

Our PD is trying to get rid of medicine wards entirely, and have us do two months of MICU instead.

We'll see what Internal Medicine says about that...

I was told by our former PD that when my program was created, various IM and EM attendings got together to design the curriculum.

The EM attendings thought we needed two months of IM wards. The IM attendings thought we needed NO IM wards.

My IM month was pretty productive. You see a lot of sick patients on the floors at my hospital. You really must be knocking on death's door to get into the ICU's where I am.

 

[mikecwru]

I actually heard that at Duke OB functions in a pretty novel way for emergency medicine residents -- that they effectively staff the OB triage and so get to deal with true OB undifferentiated complaints and emergencies, as well as get to do a set number of deliveries on the normal ward as time between triage flow permits. Seems like a novel way to satisfy an OB service that needs manpower, an ED program that needs to have obstetric rotation time, and ED residents who invariably don't want to be dealing with floor OB but need exposure to OB issues.

That's how we do OB in Cleveland.

mike

 

[DrQuinn]

I'm obviously at a new program, and have done quite a bit of retrospection on this to see what we need and dont' need at our program.

We do two months of MICU and two months of Cardiac ICU. I could probably do away with the second month of cardiac ICU, since not that much changes in cardiology, and its a relatively narrow field.

We also do a month of neurosurgery (floor and Neuro ICU), which in my opinion was probably the worst... but I did learn a lto about reading CTs, dealing with ICP issues, post op stuff, weird tumor stuff... but a pretty painful month.

Our OB was decent, we did a lot of 3rd trimester triage.

But I absolutely abhored medicine floor... we do one month of that. I suppose its good in a global sense to see what really happens when we admit these patients, but it was just... pain.

Q

 

[Jeff698]

The answer to this age-old question is not just institution-dependent, but time dependent.

I'm the one person (so far, anyway) who voted for ortho. While medicine wards left me contemplating suicide on most days, I at least learned something useful each day. Low yield, yes, but still something.

Ortho at my place is all about doing discharge summaries on patients I've never even heard of before so the upper levels can be in the OR. I guess I shouldn't complain. It was discharge patients or hold legs in the OR. I did very little bone stuff that month. The vast majority of what I've learned about ortho has come from my time in the ER.

To be fair, many of my fellow interns at my place loved ortho and got a lot out of it. Truly institution and month dependent.

BTW, the actual ortho residents were great guys that I liked almost universally. I just felt the month was a waste of time. At least I got to spend some time studying for the inservice.

Take care,
Jeff

 

[streetdoc]

It's nice to hear that you guys didn't like floor medicine...
I just finished 2 months of it for 3rd year and really didn't care for it. It's interesting, but not a good fit for me. I didn't like rounding for hours and hours (as we had 10 attendings in 8 weeks and they had to get "up-to-speed" on all the patiennts every 5-6 days), nor did i get along with the medicine personalities to well. Probably didn't due to well on the shelf to top it all off. kind of a relief to hear that is not very relevent to EM.

streetdoc

 

[Apollyon]

I actually heard that at Duke OB functions in a pretty novel way for emergency medicine residents -- that they effectively staff the OB triage and so get to deal with true OB undifferentiated complaints and emergencies, as well as get to do a set number of deliveries on the normal ward as time between triage flow permits. Seems like a novel way to satisfy an OB service that needs manpower, an ED program that needs to have obstetric rotation time, and ED residents who invariably don't want to be dealing with floor OB but need exposure to OB issues.

That's exactly why it changed to what it is - the absolute bull**** ****hole Ob/Gyn at the Cape Fear Valley Medical Center in Fayetteville NC was an incredible ****up - which is why it is, now, the way you describe it. I didn't even get my friggin' 10 deliveries at Cape Fear - and got ****ed on my evaluation from a CRAZY patient who decided to complain 2 1/2 weeks after her clinic visit with me, and I didn't get my evaluation until 10 weeks after the rotation ended. Only because Duke said they wouldn't pay anymore is why we stopped going there (despite several residents CLEARLY stating problems similar to mine), but they had to develop something else.

 

[BKN]

That's exactly why it changed to what it is - the absolute bull**** ****hole Ob/Gyn at the Cape Fear Valley Medical Center in Fayetteville NC was an incredible ****up - which is why it is, now, the way you describe it. I didn't even get my friggin' 10 deliveries at Cape Fear - and got ****ed on my evaluation from a CRAZY patient who decided to complain 2 1/2 weeks after her clinic visit with me, and I didn't get my evaluation until 10 weeks after the rotation ended. Only because Duke said they wouldn't pay anymore is why we stopped going there (despite several residents CLEARLY stating problems similar to mine), but they had to develop something else.

Well commenting on this thread has the potential to get me in the deep stuff. Don't be quoting me to your PDs. But. . .that's why the PD is essentially independent from the school. The idea is that our interest should only be your education and not service. The only real control the dept chair has over the PD is to remove him from the position. That means the chair has to do the job or find another sucker. From personal experience, I can tell you that's a big disincentive to action.

Duke's relatively new-sound like it's learning.

Over 23 years we've dropped all ward rotations except medicine (1 month). Over the years we've dropped a bunch of stuff for lack of education: Surgery Wards, Peds wards, Peds clinic, and psych wards. We've dropped NICU three times; new residents without intstitutional memory kept demanding it. We suggested they wouldn't like it and it never lasted more than 6 months before whining started again . We send em to MICU, SICU, TRAUMA/ICU (2 MONTHS) and soon PICU. The critical care units and the pit are where you learn. You also can be creative on marginal rotations that you keep. On ortho our residents get a different experience-no OR, no wards. limited clinics, take all ED consults and followups. We shortened OB to two weeks, OB triage and deliveries primarily. We used the rest of the month for a week of eye and a week of urology.

My suggestions are:
1. It is a violation of the rules to send a resident to a service primarily for service, not education.
2. Your PD can't know that a service is noneducational unless you tell him.
3. Programs are required to have you evaluate your experiences, fill out the forms.
4. If you are assertive and professional, I think your PDs will be engaged. You might not improve it for yourself, but the residents that come after may get an enhanced experience.

 

[GeneralVeers]

Well commenting on this thread has the potential to get me in the deep stuff. Don't be quoting me to your PDs. But. . .that's why the PD is essentially independent from the school. The idea is that our interest should only be your education and not service. The only real control the dept chair has over the PD is to remove him from the position. That means the chair has to do the job or find another sucker. From personal experience, I can tell you that's a big disincentive to action.

BKN you should be PD at all programs. Our old PD couldn't have cared less, and basically wanted us to put in time. Our new PD sat down with me one day during a slow shift, and asked me which rotations were useful. Because of conversations with residents he's trying to get rid of medicine wards, general surgery, and our in-house pediatrics because they are non-educational. (hopefully to be replaced by Trauma surgery and ICU)

The fact that we are there to learn, not to do "service" was precisely why I don't get along with the medicine types. They don't seem to grasp that I gain nothing from writing 10 progress notes on a weekend.

 

[BKN]

BKN you should be PD at all programs.

bite your tongue.

 

[bulgethetwine]

BKN you should be PD at all programs. Our old PD couldn't have cared less, and basically wanted us to put in time. Our new PD sat down with me one day during a slow shift, and asked me which rotations were useful. Because of conversations with residents he's trying to get rid of medicine wards, general surgery, and our in-house pediatrics because they are non-educational. (hopefully to be replaced by Trauma surgery and ICU)

The fact that we are there to learn, not to do "service" was precisely why I don't get along with the medicine types. They don't seem to grasp that I gain nothing from writing 10 progress notes on a weekend.

This is an interesting point -- I have counted two posts now that make reference to difficulty getting along with medicine types. I found the same. Sure, there were SOME great people, but some of them were just.... just... so damn tedious!

And I'm sure many would agree that a rotation is only as good as the people you work with...

 

[GeneralVeers]

This is an interesting point -- I have counted two posts now that make reference to difficulty getting along with medicine types. I found the same. Sure, there were SOME great people, but some of them were just.... just... so damn tedious!

And I'm sure many would agree that a rotation is only as good as the people you work with...

There's nothing wrong with the internal medicine people. The problem is that EM and IM are so completely different in approach. I'm trained to address the most serious problems a patient has quickly and efficiently. Medicine is trained to solve every problem, no matter how minor. Both approaches are fine for their role, but expecting the two to be compatible is too much.

What bothers me about medicine is how they mentally masturbate about a minor issue, like a glucose of 160, debate it for 2 hours, then just write for the meds they were going to write in the first place. For those of us with short attention spans, it's like slowly pulling out all of my teeth without any anesthesia.

 

[la gringa]

veers, your last comment sums up my MICU rotation. my [medicine] resident, while very nice, wants to discuss and rehash all small details several times a day. doesn't affect me too much when we have 2 pts, but when it's more than that i'm there late (all other interns left hrs ago) and feeling rushed constantly to actually DO anything once she's done yammering, attending is asking me if the stuff is done, etc. and then she stops me to yammer more. took her 20 minutes the other day to decide whether to give ativan, versed, or propofol to sedate someone, at 4am on call.

 

[turtle md]

Medicine floors ... aka "Emergency Medicine affirmation month" ... was the most pointless month for me. One thing I looked at when interviewing was how many floor months programs had - the more floor, the lower the score.

 

[waterski232002]

Thank god we don't do any floor months at my program... it's all Trauma Surgery, Critical Care, and EM (Anesthesia being the only exception)

 

[streetdoc]

No floor months at Geisinger-all ICU experience (shifts). One more reason i'm in love
What other programs have no medicine floor months?
streetdoc

 

[8744]

Medicine floors ... aka "Emergency Medicine affirmation month" ... was the most pointless month for me. One thing I looked at when interviewing was how many floor months programs had - the more floor, the lower the score.

I confess, I am learning a lot this month on medicine but seriously, why does it take an hour and a half to admit a patient for "rule out MI." I mean, fer' chrissakes he's a 52 year-old obese poorly controlled hypertensive diabetic. We stand around for half an hour puzzling like it's some goddam mystery.

 

[8744]

1. It is a violation of the rules to send a resident to a service primarily for service, not education.

This is a big problem, in my opinion, at Duke. On many rotations it is obvious that we are just warm medically trained bodies who's primary job is to do the paperwork so the attendings don't have to. To their credit, on the medicine rotation I am now on they really emphasise teaching which is unusual.

CAD in particular, at Duke is just a scut-slog for the interns. Very little teaching. After the first week you learn everything you need to know and then you just grind on.

 

[Koko]

No floor months at Geisinger-all ICU experience (shifts). One more reason i'm in love
What other programs have no medicine floor months?
streetdoc

Most I looked at don't have them anymore. Mayo no longer does.

 

[Eidolon6]

It is ironic internal medicine floor rotations are being phase out of some EM residency programs...given that EM evolved primarily from generalists and IM doctors doing acute care. I suspect a fair amount of "bread and butter" medicine is missed out on in these places....scary. Some of the sharpest ER folks I've worked with were internists in former lives/training.

But then again...perhaps knowing just a little is worse than knowing nothing at all.

 

[bulgethetwine]

It is ironic internal medicine floor rotations are being phase out of some EM residency programs...given that EM evolved primarily from generalists and IM doctors doing acute care. I suspect a fair amount of "bread and butter" medicine is missed out on in these places....scary. Some of the sharpest ER folks I've worked with were internists in former lives/training.

But then again...perhaps knowing just a little is worse than knowing nothing at all.

If by bread and butter you mean the delicacies of placement, yup, you're right.

Seriously, without just dropping a cynical comment and running (as is usually my modus op) your point is well taken. But some ill-defined sense of missing out on "bread and butter" medicine is not really the case. We still get training in the ICU settings. The on-going treatment of things like, for instance, COPD flairs and post-MI care (are these what you meant by bread and butter?) really isn't relevant. Or I should say, it is not AS relevant as the ability to diagnose and initiate acute care and stabilizing measures (and I am careful not to convey a complete ignorance to "on-going" care; for surely in some hospitals, the length of duration in an ED that a patient might spend certainly results in "on-going" care.

I could be open to persuasion, though. Can you name any specific cases and subsequent lessons that you think you learned (or one might) while on an internal medicine ward that are not only relevant to emergency medicine, but are experiences which couldn't be obtained more efficiently on other rotations e.g. MICU or indeed emergency department shifts?

 

[Squad51]

It is ironic internal medicine floor rotations are being phase out of some EM residency programs...given that EM evolved primarily from generalists and IM doctors doing acute care. I suspect a fair amount of "bread and butter" medicine is missed out on in these places....scary. Some of the sharpest ER folks I've worked with were internists in former lives/training.

But then again...perhaps knowing just a little is worse than knowing nothing at all.

So, if Koko is right and Mayo no longer does IM, you think they miss "bread and butter" medicine.

Let me guess, you are an IM resident, right?

 

[JackBauERfan]

No floor months at Geisinger-all ICU experience (shifts). One more reason i'm in love
What other programs have no medicine floor months?
streetdoc

I don't see any medicine floor months at Lincoln, but not there yet, so dont' know if they are planning any changes...and its 4 years, of which i'm doing a prelim medicine.

 

[waterski232002]

No floor months of any kind at the University of Chicago.... All ICU.

 

[Eidolon6]

To qualify "bread and butter", what I mean is the process of performing a diagnostic workup and recognized insideous diseases that aren't on the 3-5 item problem list found on most complaint driven ED H&P forms. Understanding how to work-up any medical condition that may present to the ER beyond the simple determination of whether they need to be admitted or not. Doing medicine floor work has more to do with the process of identifying a problem, characterizing it then moving the patient on to the appropriate therapy...wherever that may be....much like the ER in some respects...
I think its important to know how to construct a differential longer than three to five items found on the ER H&P template and to understand how to efficiently work-up complex diseases, whether chronic or acute....its about understanding the process. The ICU encorporates some of these elements of these but remember that some workup is limited in the ICU because people are so darn sick. As a pulmonologist and intensivist, it makes it easier to understand whats going on with a patient when the ER doc trying to admit the patient to me understands it and can have a brief intelligent dialogue about it. It really frustrates me when I see a patient admitted after 2 or 3 visits to the ER and rounds of treatment for pneumonia when they actually have something more insideous. Yeah, dispo in IM floor sucks...but if that's all you think it is then you're missing the point. If you extended the argument, then why should ER residents do surgery rotations if they don't go to the operating room to operate?..maybe they can watch videotapes on how to sew up lacs instead...

I fear that ER training programs shunning medicine because the residents don't like the work/pace/patients/paperwork will translate into substandard training and likely substandard ER physicians. Medicine and medicine subspecialties are the largest admitting groups in most hospitals so it would probably behoove the community charged with dispositioning those patients from the ER to the inpatient service to understand the structure, function, culture and purpose of the specialties to which they are admitting.

I would actually argue that increasing the training interaction is a better idea. Our ER and Pulm/CCM departments, in addition to having ER residents rotating through the medical services and MICU have started joint conferences to marry patients evaluated in the ER to their workups in the ICU and on the floor...to see both sides of the same coin and helps tie in patient presentations with diseases that are often not considered by the ER physician in their work-ups.

 

[kbrown]

I think that your point is well-taken, but I do disagree to a point.

As have most of us, I HAVE been on both sides of the coin. We all do medicine as medical students. For those of us who choose to do EM, we also do a couple of EM rotations. That being said I have been the recipient of some pretty sh*!!y admits from lazy ED docs (like the DKA that came in with BS of 800+, large gap, and was admitted to the floor without one single drop of insulin, inexcusable in my book). I have also had to argue with a tired, over-worked or maybe just lazy IM resident about the need to admit a patient. One example that comes to mind is a 40ish white male with 2-3 weeks of malaise, sore throat, fevers, loss of appetite, nausea, some sick contacts in the history, failure of antibiotic therapy, etc...(you can probably see where this is going) that has recently worsened.

Because he has been seen by PCP a couple of times for this, many labs have already been drawn, but due to his acute exacerbation of a subacute illness we draw some more. While waiting for lab to come we sift through computer logs of what PCP has done. Just yesterday he had an abd CT done, that showed diffuse lymphadenopathy in the abd cavity. Well, the diagnosis is likely some lymphoma, but being that this is the ED, what the hell are we gonna do about it. How much more should we work him up, how long should our differential be? If my differential were 3 or 23 would it really matter? I am most certainly not qualified to start any sort of treatment for this patient, as quite frankly as a general internist, neither are you. You are gonna do just what I would do, call the heme/onc people after you run a few more tests, or perform a biopsy. Me sending this patient up to you without having consider ALL of the possible types of lymphoma this man has is not gonna do anything but delay his treatment. But let's suppose for a second that he doesn't have lymphoma, and that we didn't have that abd CT from the day before. You can bet your butt that the ED will do a workup for an infectious cause, surgical cause, ingestion, etc... Our differentials our geared FIRST, towards deciding "life or limb threat", then morbidity, then symptomatic relief of minor problem. We just don't use the same methodical, mental mastur...that internists do to make decisions because time isn't a luxury we have.

I understand that it is important for all physicians to recoginze some of the fundamental (bread and butter) things that plague other specialties. Having this fundamental understanding will make sure that you don't call the admitting team or consultant for something that you aren't uncomfortable with when it really isn't that serious. I will agree completely with that rationalization for IM rotations.

There is utility in medicine months, I don't agree that they should completely be abolished (for the above mentioned reason), but I sure as hell don't think that there should be MORE. A month of ID, Nephro, or Cards, should really be enough with prob 3-6 months of various ICU's (PICU, Trauma ICU, SICU, Neuro ICU, etc...)

 

[pushinepi2]

...Univ of Maryland has phased out floor months as well. Though I think we benefit from two MICU months during our intern year, there is probably some UTILITY within every rotation. The challenge is to figure out how to graduate the most well rounded and capable emergency physician possible in three to four short years. The debate over whether to completely eliminate floors and wards from an EM residency can take up an entire message board!

One thing I do agree with completely is that emergency medicine residents benefit from interface with other hospital departments. I don't see how rotating in the MICU as opposed to the floor represents some type of alienation / disconnect between EM and IM programs. Working together on some of the more critically ill patients in the hospital helps with the formulation of complex differentials, treatment plans, and the cultivation of valuable relationships. EM residents do well in an intensive care environment; we can learn from a senior IM resident's more intricate understanding of pathophysiology while perfecting our resuscitation/critical care procedural skills.

-push

 

[Squad51]

To qualify "bread and butter", what I mean is the process of performing a diagnostic workup and recognized insideous diseases that aren't on the 3-5 item problem list found on most complaint driven ED H&P forms. Understanding how to work-up any medical condition that may present to the ER beyond the simple determination of whether they need to be admitted or not. Doing medicine floor work has more to do with the process of identifying a problem, characterizing it then moving the patient on to the appropriate therapy...wherever that may be....much like the ER in some respects...

Wow, that is actually insulting when you read between the lines. Do you honestly think that an EP's knowledge is limited to what is on the forms? Do you honestly think "complaint driven ED H&P forms" are used at every program. And why is it that you believe that the presentation of "bread and butter" patients to the ED, and an EM resident's treatment of the same, is so sub-par if not guided by the endless pontification of an IM resident?

I think its important to know how to construct a differential longer than three to five items found on the ER H&P template and to understand how to efficiently work-up complex diseases, whether chronic or acute....its about understanding the process.

Well, again, I think that you are a bit arrogant to suggest that EM needs IM to accomplish this. And I think many EPs would disagree with you, there are significant limits to the work-up of chronic problems that are not the acute cause of presentation. Let me give you a "for instance". A 43 year old M comes in with a twisted ankle. No syncope or concern for pre-injury pathology, he injured it sliding into 2nd base playing softball. Triage notes his BP at 150/100. Repeat BP with good pain control and >2 hours since injury is still 150/100. Should the patient be "efficiently worked up" in the ED. Many leaders in our field (well I assume it will be my field) say "no". Refer to a PCP. It could be considered unethical to begin long term therapy when you have no method to follow up on the progress. So, non-emergent presentations of chronic illnesses are not really the EP's concern.

The ICU encorporates some of these elements of these but remember that some workup is limited in the ICU because people are so darn sick.

Yep, but the sick is where the needed experience is...

As a pulmonologist and intensivist, it makes it easier to understand whats going on with a patient when the ER doc trying to admit the patient to me understands it and can have a brief intelligent dialogue about it.

Exactly...

It really frustrates me when I see a patient admitted after 2 or 3 visits to the ER and rounds of treatment for pneumonia when they actually have something more insideous.

And it is so much less frustrating for the EP who recieves the critically sick patient that has seen there PCP 4 times last month and could've been brought into the hospital before they needed the unit? Everyone misses - even internists. Not excusing it, but if you are looking for all other services to be 100% correct you will only continue to be frustrated.

Yeah, dispo in IM floor sucks...but if that's all you think it is then you're missing the point. If you extended the argument, then why should ER residents do surgery rotations if they don't go to the operating room to operate?

Actually, few do rotations in the OR.

..maybe they can watch videotapes on how to sew up lacs instead...

Or maybe they can sew one of the hundreds swen in the ED each day. It always amused me to hear a patient insist on "plastic surgery" to come down and sew a lac. Yep, you can have the senior EM resident who has sewn hundreds of lac or the plastics intern who might have closed a surgical incision once or twice...

I fear that ER training programs shunning medicine because the residents don't like the work/pace/patients/paperwork will translate into substandard training and likely substandard ER physicians.

And I fear that the continued arrogance of residents like you who seem to regard emergency medicine as "less than" a unique subspecialty incapable of training residents without the "learned" aid of internists will translate into such poor communication that patient care will be effected.

Medicine and medicine subspecialties are the largest admitting groups in most hospitals so it would probably behoove the community charged with dispositioning those patients from the ER to the inpatient service to understand the structure, function, culture and purpose of the specialties to which they are admitting.

And in the non-academic world, where ED referrals put food on the internist's table, you might find the opposite to be true.

I would actually argue that increasing the training interaction is a better idea. Our ER and Pulm/CCM departments, in addition to having ER residents rotating through the medical services and MICU have started joint conferences to marry patients evaluated in the ER to their workups in the ICU and on the floor...to see both sides of the same coin and helps tie in patient presentations with diseases that are often not considered by the ER physician in their work-ups.

I will agree, joint conferences and learning experiences are a good idea...