Benefits of EM program with no IM rotation

[DrJavaSunflower]

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I interviewed at some EM programs that made an emphasis on not having an IM rotation on their curriculum. Truth behold, I hate IM/ rounding. But, I thought we would still need to learn IM somehow? I am interested in hearing from you guys about the benefits and challenges of not having an IM rotation. Should it impact my rank order list?

 

[Fox800]

I interviewed at some EM programs that made an emphasis on not having an IM rotation on their curriculum. Truth behold, I hate IM/ rounding. But, I thought we would still need to learn IM somehow? I am interested in hearing from you guys about the benefits and challenges of not having an IM rotation. Should it impact my rank order list?

I have a feeling that you will get the most important parts of an IM rotation during your MICU months.

 

[link2swim06]

No, most of the time that IM rotation gets replaced with a MICU month. You will get plenty of experience there.

 

[alpinism]

I interviewed at some EM programs that made an emphasis on not having an IM rotation on their curriculum. Truth behold, I hate IM/ rounding. But, I thought we would still need to learn IM somehow? I am interested in hearing from you guys about the benefits and challenges of not having an IM rotation. Should it impact my rank order list?

Why?

Any program that has a IM floor month is either weak or just using its residents for cheap labor.

The goal of EM residency is to see as many sick patients as possible. This means spending as much time as possible in the ED and ICU.

 

[b-real]

How much IM are you going to learn in one rotation anyway?

 

[DO2016EM]

I ranked programs without IM months higher. I feel that MICU months are more beneficial than IM. The only thing I feel an IM month will teach is what the floors expect when you admit a patient. And, really, who cares what they think, right?

 

[Siggy]

Most off service rotations are low yield. IM residents feel the same thing for their 1 month in the ED (exposure to trauma and kids... oh boy! The IM intern would have more benefit from a second MICU rotation than an EM rotation), however...

I ranked programs without IM months higher. I feel that MICU months are more beneficial than IM. The only thing I feel an IM month will teach is what the floors expect when you admit a patient. And, really, who cares what they think, right?

::comes to ED::
::Writes consult note stating no inpatient need::
::Leaves ED to discharge patient::
::Lets the ED enjoy their Press Ganey score::

There's benefit for the IM resident to know how throughput works in the ED.
There's benefit for the EM resident to know why IM can be... hesitant... for bridging some patients and why we can't just appear 5 seconds after the ED calls for admission.

 

[gman33]

I wouldn't be concerned about having an IM month or not.
There is something to be learned, but you will be fine without it.

My program had no IM rotations.
We did a ton of ICU time, and truth be told, half of that ends up being straight IM with patients in the unit who have no real need to be there.

 

[DrJavaSunflower]

Thanks all for your thoughts! One month of IM I could deal with.. but I was not sure if it would be something I would regret signing up. lol

 

[Dre8]

Thanks all for your thoughts! One month of IM I could deal with.. but I was not sure if it would be something I would regret signing up. lol

At my program we did no time on the floor, but we did several ICU months. I do sometimes wish I had a better understanding of what happens routinely to my admitted or obs'ed patients because families ask me, and because I generally think I'd be a better Doctor. But I'm pretty sure it's not worth a month of our limited residency time.

 

[pulmoblast]

Ironic that before EM started out as a speciality, EDs were usually staffed by IM attendings, since 80% of what came through the the door was IM stuff...

 

[Apollyon]

Ironic that before EM started out as a speciality, EDs were usually staffed by IM attendings, since 80% of what came through the the door was IM stuff...

Yeah, and, here we are, 40 years later.

And give our family practice brothers/sisters their props, too!

 

[engineeredout]

So I float on both sides so admittedly I probably have a biased opinion

Overall, I agree with a lot of the ED relevant medicine gets learned in the MICU ( in addition to procedural fun)

As far as floor medicine months go, I think there is value in seeing things from the opposite side. Seeing when someone in the ED goes "just admit him and move on", so you can have an idea of what is involved, how people move throughout the hospital, see certain patients who look well and then decompensate, what work ups could possibly be started in the ed that might be beneficial etc... It's similar to sub specialty rotations, which at least for me consist of the specialists saying what they would want to have happened in The ED in this patient and that patient etc... Admissions especially and coming up with an actual treatment plan have educational value as well.

No, daily progress notes not likely to be helpful. No, discharge summaries/dictation not likely to be helpful. But there is value to be had if you're on a rotation. A single IM rotation does not spell disaster for a residency program.

 

[shoal007]

Ya i echo some of the above statements. I did a residency without IM floor months and can say I wish I kinda did, so I understood what the patient should expect, what they can and cannot handle and just understand their workflow better. I work in an ED with an observation unit and I'm supposed to run it. It is very hard understanding endpoints, good patient care without the IM experience but I'm getting there slowly.

Sent from my VS986 using Tapatalk

 

[filhodeinferno]

Too much emphasis on IM month vs non-IM month. It will not change your life much for the better or worse.

 

[exsanguination]

This is an aspect that you shouldn't care about. The presence or absence of an IM floor month is irrelevant in the long term. Pick a program that will give you acuity, depth and breadth, in a location that you're cool with. Nothing else really matters. If you go to an ACGME accredited program, you will come out a competent EM doc. Additionally residency is a lot of what you put into it. You could go to the fanciest name brand spot and still be mediocre if you don't put your blood, sweat, and tears into the game.

 

[b-real]

Most off service rotations are low yield. IM residents feel the same thing for their 1 month in the ED (exposure to trauma and kids... oh boy! The IM intern would have more benefit from a second MICU rotation than an EM rotation), however...



::comes to ED::
::Writes consult note stating no inpatient need::
::Leaves ED to discharge patient::
::Lets the ED enjoy their Press Ganey score::

There's benefit for the IM resident to know how throughput works in the ED.
There's benefit for the EM resident to know why IM can be... hesitant... for bridging some patients and why we can't just appear 5 seconds after the ED calls for admission.

Except that the places where I've trained and worked, once the ED attending says they're admitted, they're admitted. The IM resident/attending is free to come down to the ED, write their note and discharge the patient, but they're admitted regardless.

 

[deleted547339]

Why?

Any program that has a IM floor month is either weak or just using its residents for cheap labor.

That's just not true.

 

[Daiphon]

So I float on both sides so admittedly I probably have a biased opinion

Overall, I agree with a lot of the ED relevant medicine gets learned in the MICU ( in addition to procedural fun)

As far as floor medicine months go, I think there is value in seeing things from the opposite side. Seeing when someone in the ED goes "just admit him and move on", so you can have an idea of what is involved, how people move throughout the hospital, see certain patients who look well and then decompensate, what work ups could possibly be started in the ed that might be beneficial etc... It's similar to sub specialty rotations, which at least for me consist of the specialists saying what they would want to have happened in The ED in this patient and that patient etc... Admissions especially and coming up with an actual treatment plan have educational value as well.

No, daily progress notes not likely to be helpful. No, discharge summaries/dictation not likely to be helpful. But there is value to be had if you're on a rotation. A single IM rotation does not spell disaster for a residency program.

Yeah. I concur... the other issue is your admits. I was in the last class of my residency to do a floor month, and let me tell you how much pushback I got from the IM side after my month upstairs = zero.

I knew what they wanted, but more importantly developed relationships by virtue of working with them that significantly improved my efficiency - "hey, it's d, I got X for ya, ok?" "Ok." <click>. Next patient...

I would caution against multiple non-ICU months; but a single one oughtn't make or break a program for you.

-d

Semper Brunneis Pallium

 

[deleted547339]

Yeah. I concur... the other issue is your admits. I was in the last class of my residency to do a floor month, and let me tell you how much pushback I got from the IM side after my month upstairs = zero.

I knew what they wanted, but more importantly developed relationships by virtue of working with them that significantly improved my efficiency - "hey, it's d, I got X for ya, ok?" "Ok." <click>. Next patient...

I would caution against multiple non-ICU months; but a single one oughtn't make or break a program for you.

-d

Semper Brunneis Pallium

This is exactly my experience. After rotating on the IM service and showing I was hard-working, well-read and a team player, admitting got much easier.

It also made me have a better appreciation for what needs to come in the hospital and what doesn't (i.e. minimizing the "something is wrong, I want them admitted").

Lastly, it made me understand what is and is not appropriate for a floor or step down setting. Understanding nursing limitations on the floor makes me able to more appropriately dispo a patient.

 

[dotcb]

I did 2 months of floor medicine intern year. It was time well spent. Most of the patients you admit from the ED will be bread and butter inpatient medicine. It's worth knowing what happens to them in the hospital so you can best decide who needs to be admitted and what the benefit of admission may be.

 

[Old_Mil]

I interviewed at some EM programs that made an emphasis on not having an IM rotation on their curriculum. Truth behold, I hate IM/ rounding. But, I thought we would still need to learn IM somehow? I am interested in hearing from you guys about the benefits and challenges of not having an IM rotation. Should it impact my rank order list?

Learning how to do floor work doesn't make you a more qualified emergency room doctor any more than working at a gas station makes you a more qualified member of a NASCAR pit crew.

Off service rotations are the free labor your PD provides his colleagues for peaceful coexistence.

Go somewhere where you have to do as little of it as possible.

Residency is the only screwed up universe in which trainees are intentionally deprived of experience relevant to their intended job description so that other institutional priorities can be met.

"Emergency medicine is best learned in the emergency department." Go somewhere the PD actually believes this and fights to keep his residents in the shop as much as possible.

Outside of PICU and maybe ophthalmology (just because the concentration of really emergent presentations in these two fields is so low) off service rotations are ridiculously low yield.

 

[Angry Birds]

Ironic that before EM started out as a speciality, EDs were usually staffed by IM attendings, since 80% of what came through the the door was IM stuff...

The ER was staffed back then by people from many different specialties, not just IM. And no, I don't think 80 percent is IM related.

 

[Tenk]

The only thing you will learn on an IM month is why you should be thankful for choosing EM.

 

[TooMuchResearch]

You learn what happens to people by spending time in the ICU, including those that get admitted to a lower level of care and get worse or the diagnosis was missed by the ED or inpatient team and they got worse.

 

[deleted109597]

Did you people not have to do IM during medical school? Could you not figure out what could and could not be done inpatient then?
IM months are free labor. Sure, you can build relationships with the other services, but you could do that in the MICU as well.

If you don't know what can be done upstairs and therefore don't know what you're admitting someone for, then you need to go back to school.

 

[Janders]

My program had a single floor IM month. I did it as my first rotation as an intern... at the time I thought it was vaguely useful. Honestly it was a lovely, easy way to transition from med school to being an intern-- floor medicine is similar everywhere, and we spent a ton of time on the wards as med studs. Lucked out to have residents/attendings that were excellent teachers as well.

Most of my classmates second half of the year found it largely a waste of time. It was dropped from our curriculum a year or two later. Previously we'd tried a month on cardiology-wards instead; that was also dropped after a trial as not a terribly useful rotation.

Anyway, I don't think a single floor month (or lack thereof) is a make-or-break distinction between programs, personally.

 

[DrJavaSunflower]

If you don't know what can be done upstairs and therefore don't know what you're admitting someone for, then you need to go back to school.

smh

 

[deleted547339]

Did you people not have to do IM during medical school? Could you not figure out what could and could not be done inpatient then?
IM months are free labor. Sure, you can build relationships with the other services, but you could do that in the MICU as well.

If you don't know what can be done upstairs and therefore don't know what you're admitting someone for, then you need to go back to school.

Yes, there is no difference between being the resident placing orders, writing your notes, answering pages, admitting new patients, dictating discharge summaries, etc than there is being the med student.

 

[deleted109597]

Yes, there is no difference between being the resident placing orders, writing your notes, answering pages, admitting new patients, dictating discharge summaries, etc than there is being the med student.

If you're implying that I think seeing what one does, and doing it are the same, then no, you're wrong. It is different to see it than to do it.
However, if you can't figure out what can be done by watching others do it, then yeah, you're either an idiot or just lazy and not watching closely. Your free labor to renew tylenol and bowel regimen orders while arranging nursing home placement is better served doing pretty much anything else. There's a reason I'm not the only person on here who argues against it. Should it be the most important reason for ranking? Probably not. But it isn't irrelevant either.
It's not as if I a)wasn't a medical student, b)wasn't a resident that did a floor month, and c)now teach residents. I think I have enough perspective to make a decision on this.

 

[deleted547339]

If you're implying that I think seeing what one does, and doing it are the same, then no, you're wrong. It is different to see it than to do it.
However, if you can't figure out what can be done by watching others do it, then yeah, you're either an idiot or just lazy and not watching closely. Your free labor to renew tylenol and bowel regimen orders while arranging nursing home placement is better served doing pretty much anything else. There's a reason I'm not the only person on here who argues against it. Should it be the most important reason for ranking? Probably not. But it isn't irrelevant either.
It's not as if I a)wasn't a medical student, b)wasn't a resident that did a floor month, and c)now teach residents. I think I have enough perspective to make a decision on this.

I can assure you I'm neither an idiot nor lazy, that being said, I learned a lot from my medicine month.

 

[deleted109597]

I can assure you I'm neither an idiot nor lazy, that being said, I learned a lot from my medicine month.

Early on, you might learn the ubiquitous process called "being a doctor". It's really not much different between any specialty for the first few months. You need to figure out what meds treat what conditions, how the pagers work, what to do for fevers, how to look at the EMR, etc.
If you're saying you learned a lot at the end of your intern year from floor medicine, then I'm curious as to what it was.

 

[deleted547339]

Early on, you might learn the ubiquitous process called "being a doctor". It's really not much different between any specialty for the first few months. You need to figure out what meds treat what conditions, how the pagers work, what to do for fevers, how to look at the EMR, etc.
If you're saying you learned a lot at the end of your intern year from floor medicine, then I'm curious as to what it was.

The most important thing I learned from medicine wards was learning nursing capabilities. Seeing patients grossly mismanaged on the floor gave me a much better understanding of what is appropriate for the floor, the step-down unit and the ICU.

It also gave me an appreciation for the speed at which things happen upstairs (or lack thereof).

 

[TooMuchResearch]

The most important thing I learned from medicine wards was learning nursing capabilities. Seeing patients grossly mismanaged on the floor gave me a much better understanding of what is appropriate for the floor, the step-down unit and the ICU.

It also gave me an appreciation for the speed at which things happen upstairs (or lack thereof).

I learned that in the ICU and from staff in the ED.

Edit: and from discussions with hospitalist.

 

[deleted109597]

The most important thing I learned from medicine wards was learning nursing capabilities. Seeing patients grossly mismanaged on the floor gave me a much better understanding of what is appropriate for the floor, the step-down unit and the ICU.

It also gave me an appreciation for the speed at which things happen upstairs (or lack thereof).

And you didn't pick any of that up as a student? You've never had an ED nurse complain because of the floor nurses and MEWS scores, or meds hanging, or 17 million other things? Honestly?
Also, using a floor month to learn nursing will serve you none in your next job. Each hospital has their own rules. At my residency training site, low dose pressors, insulin drips, and cardizem drips all went to the floor. At my current job, all of those go to the ICU. Hell, q1 hour neuro checks has to go to the ICU here.

 

[PlutoBoy]

It is a major benefit

 

[winkleweizen]

One IM month shouldn't push a program up or down, but if they are making u do multiple months and an infectious disease month, etc.....I question the set up of that program

 

[Apollyon]

It is a major benefit

You saying that has little to no provenance here, unless you can give reasons, germane to EM, from you as an IM doc.

Or, you are just trolling.

 

[gutonc]

You saying that has little to no provenance here, unless you can give reasons, germane to EM, from you as an IM doc.

Or, you are just trolling.

It's that one.

 

[PlutoBoy]

You saying that has little to no provenance here, unless you can give reasons, germane to EM, from you as an IM doc.

Or, you are just trolling.

Because rounding sucks.

 

[gman33]

I think residents should spend a month alternating between living in nursing homes, homeless shelters and low income housing. You will d/c 3 times as many patients as you admit.

You need to learn the capabilities of those environments.

 

[Angry Birds]

The only thing you will learn on an IM month is why you should be thankful for choosing EM.

Haha, I agree that my IM rotation did make me thankful for EM, mostly since I hate rounds.

Even so, even though I don't think an IM rotation is *mandatory*, but clearly IM rotation(s) are very helpful. What I really enjoyed was responding to Rapid Responses...which, to be honest, I would do in a totally different way after having trained EM. (Step 1: Throw away the chart.)

I don't think it's right to compare the floor to a nursing home facility, etc. even though I understand the point. The reality is that we work very closely with our hospitalist colleagues, and I think it is beneficial for both specialties to wear the others' shoes.

In this regard, however, I guess the criticism I have is that--at least in my program--we let the IM residents doing an EM rotation pretty much see like <0.5 patients an hour, which doesn't allow them to realize the time pressures we operate under.

 

[goodoldalky]

It is neither make or break. I did one month of IM as a resident and found it useful. Full disclosure I marked it as a con when I was considering the pros/cons of residency programs, but at the end of residency I reviewed it as a "must keep" rotation. As an EM doc I rarely (ideally) call anyone for advice. I am calling them to get them to do something specific, I already know what it is. In order to best get them to do what I want them to do, I have to know what they do and how they approach a new patient with pretty intense detail. It helps to do surgery, trauma, IM, PICU... etc. ASSUMING the rotation is good. Mine happened to involve a fair number of floor codes, etc., where most of the other residents did not have the skill nor desire to intubate, place lines, or run the code itself, so I got a lot of experience as an intern. If it's a mind numbing bang your head against the wall waste of time rotation where you are scutted out on the other hand, then that's another thing entirely. But you are a fool if you think you cannot learn something from a good IM floor month that will help you be a better emergency physician. My .02.

 

[Angry Birds]

I think residents should spend a month alternating between living in nursing homes, homeless shelters and low income housing. You will d/c 3 times as many patients as you admit.

You need to learn the capabilities of those environments.

Actually, joking aside, it would be useful to be exposed to these environments at some point in one's medical career.

 

[gman33]

In my fm rotation in med school, I went to some nursing homes and did some home visits.

Just assume nothing will be done.

 

[deleted109597]

Mine happened to involve a fair number of floor codes, etc., where most of the other residents did not have the skill nor desire to intubate, place lines, or run the code itself, so I got a lot of experience as an intern. If it's a mind numbing bang your head against the wall waste of time rotation where you are scutted out on the other hand, then that's another thing entirely. But you are a fool if you think you cannot learn something from a good IM floor month that will help you be a better emergency physician. My .02.

Your logic is circular at best. Sure, you can learn something on an IM month that will make you a better EP. But anything you could learn there could also be learned somewhere else, with higher density.
Let's play the thought game. Everything you said that makes an IM floor month worthwhile could also be done with a month of IM clinic. So go through all of the posts above and replace floor with clinic, and see if the meaning substantially changes. Because it won't.

You want to respond to codes? Make it part of your ED responsibility like they do at LA. Then you can do it all throughout residency, instead of just one solitary month.

Literally everyone has said something to the effect of "if it's a good month", but then doesn't quantify a good month. I'll wait for everyone to jump in and announce what makes floor medicine and only floor medicine worthwhile to an emergency physician. Something they can only learn on the floor, and not on, say, MICU, or neurology, or any other rotation where you're upstairs reading other people's notes.

And clearly, no matter how hard we work on any service, we still rarely get any respect from those upstairs. Yet they make us have the same workload as any other floor scutmonkey. And we apparently can't make them equal to our interns when they come to the ED. So why waste 28-31 days on that?

 

[deleted547339]

Your logic is circular at best. Sure, you can learn something on an IM month that will make you a better EP. But anything you could learn there could also be learned somewhere else, with higher density.
Let's play the thought game. Everything you said that makes an IM floor month worthwhile could also be done with a month of IM clinic. So go through all of the posts above and replace floor with clinic, and see if the meaning substantially changes. Because it won't.

You want to respond to codes? Make it part of your ED responsibility like they do at LA. Then you can do it all throughout residency, instead of just one solitary month.

Literally everyone has said something to the effect of "if it's a good month", but then doesn't quantify a good month. I'll wait for everyone to jump in and announce what makes floor medicine and only floor medicine worthwhile to an emergency physician. Something they can only learn on the floor, and not on, say, MICU, or neurology, or any other rotation where you're upstairs reading other people's notes.

And clearly, no matter how hard we work on any service, we still rarely get any respect from those upstairs. Yet they make us have the same workload as any other floor scutmonkey. And we apparently can't make them equal to our interns when they come to the ED. So why waste 28-31 days on that?

We get it. You think there is no utility in a floor month.

 

[deleted109597]

We get it. You think there is no utility in a floor month.

Apparently you don't.
It's not that there's no utility. Hell, there could be utility from watching every episode of ER.
It's just that there's better utility elsewhere.

I'm still waiting for someone to come up with something the IM floor month does better than MICU.

 

[deleted547339]

Apparently you don't.
It's not that there's no utility. Hell, there could be utility from watching every episode of ER.
It's just that there's better utility elsewhere.

I'm still waiting for someone to come up with something the IM floor month does better than MICU.

I've learned that it is unwise to argue with people who have already made up their mind. I told you, above, my opinion on the matter and why.

 

[goodoldalky]

Haha, typical internet message board thread derailing going on here.

Look, it's not that hard. Some IM floor rotations are good as an EM resident. Many are bad. You need to find out exactly what types of experiences the residents at the program have had, and what their take on it is. If they say, "I know it sounds sucky, but I liked it, and here is why it made me a better doctor and I'm in favor of keeping it," then that is worth something. If the typical response is, on the other hand, "Yup, typical intern terrible rotation! At least we don't have to do it the rest of our lives!", then it's probably terrible.