Cerebral Programs

[odoreater]

I am interested in an ER program that is not focused on the surgical aspect/trauma but on the acute management of complicated medical emergencies. I enjoy the thinking that goes into a medical emergency as opposed to the reactions of a surgical one.

Can any of you suggest a program that fits this description? A program that almost functions like a medicine one (not the rounding etc) in so far as they take the time to teach you how to assemble a complex differential based upon a cryptic medical presentation? Or, are there any programs that are clasically known as "cerebral programs?"

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[NinerNiner999]

Christiana, Tampa, Maryland to name a few

 

[The White Coat Investor]

Yea...go to Maryland. You'll hardly see Trauma at all. Baltimore is a really safe city.

But seriously....Sounds to me like you're looking for a benign medicine residency, not an EM residency. Trust me, you'll see plenty of cryptic presentations wherever you go, but you'll have a hard time finding a job where your partners (and ancillary staff) appreciate you assembling a complex differential, much less working it up. Its EM...treat the emergent, see the urgent, and turf the rest to where it should have presented in the first place (or admit it to someone who enjoys "assembling a complex differential.") As someone has said before, in EM you hit the green and let someone else do the putting. Your differentials include the most common diseases causing the chief complaint and the most life-threatening diseases causing the chief complaint.

No offense, but make sure you're making the right specialty choice.

All of that being said, you can certainly choose a practice where you will see mostly medical complaints....look for a community hospital in an up-scale part of town where the board looks like this:


1 CP
2 CP
3 CP
4 SOB
5 SOB
6 Weak n dizzy
7 Weak n dizzy
8 Weak n dizzy
9 Weak n dizzy
10 Weak n dizzy
11 CP
12 CP
13 CP
14 SOB
15 SOB
16 Weak n dizzy
17 Weak n dizzy
18 Weak n dizzy
19 Weak n dizzy
20 Weak n dizzy, SOB, and CP

I wouldn't rush to train in a place where the board looks like that though.

 

[SHOX]

I agree with Desperado...

If dying... ABC... stabilize and turf.

If not-dying... are they fixable? If yes, fix and turf. If not fixable by you, then turf.

I love the golf analogy in prior post!

I would encourage anyone out there to go to a place where you can see a wide array of pathology, >60k visits, and actually get to do pocedures (I don't mean IVs and carting patients around).

If your programs have case conferences then you can mentally masturbate all you want like the fleas do (I can say that being a pat-time flea).

 

[SHOX]

I agree with Desperado...

If dying... ABC... stabilize and turf.

If not-dying... are they fixable? If yes, fix and turf. If not fixable by you, then turf.

I love the golf analogy in prior post!

I would encourage anyone out there to go to a place where you can see a wide array of pathology, >60k visits, and actually get to do pocedures (I don't mean IVs and carting patients around).

If the programs have case conferences then you can mentally masturbate all you want like the fleas do (I can say that being a pat-time flea).

 

[GCS:3]

Originally posted by Desperado
As someone has said before, in EM you hit the green and let someone else do the putting.

In emergency, while the goal is to treat or turf as appropriate, you still need to be "cerebral" to some extent. I don't think you should sit there and ponder a differential for 2 hours, but your differential should still be somewhat complete. This is especially true in residency, where your goal is to learn to recognize diagnoses. Without the "cerebral" element, EM docs would fall into the traps of missing critical diagnoses. We all know where that leads. Damn you Edgar Snyder.

I agree that a community ED would be a good place for you if you want a slower experience with more teaching/thinking/reading time. However, off service rotations contribute too, so maybe a big name program could work, too...

 

[Apollyon]

Originally posted by SHOX
I love the golf analogy in prior post!

That was me!

http://forums.studentdoctor.net/showthread.php?s=&postid=919233&highlight=#post919233

Originally posted by Apollyon
I liken EM to a golf course. A lot of cases are putt-putt. Bigger ones, we just have to stay on the fairway, and get to the green. On occasion, we will hole out, but just being on the green is good enough - surgeons and IM docs (or other specialists) will come in to putt, once we've gotten the ball (patient) there.

 

[frog4brooke]

I just interviewed at UVA for EM and they discussed their complex medical cases quite a bit and they do not have a huge trauma population.

Maybe this is the pace you are looking for? If so, U of MD is probably not what you are wanting (large trauma population).

B

 

[The White Coat Investor]

You might consider Wright State as well. Although I think they get their share of trauma when they're at their flagship hospital, they rotate at 3 others, one of which is a country club with tons of medical patients, and one of which is on-base at Wright-Patterson, where its pretty slow giving you lots of time to expand your differential diagnosis of some general's cold.

 

[ERMudPhud]

I've heard that Oregon is a very academic/cerebral program.

I have to disagree with many of the posters about making difficult diagnoses in the ER. I think one of the most rewarding aspects of my job is being the first to figure out what is wrong with a patient, especially if they are very ill or have seen multiple physicians before. Sometimes making the right diagnosis is critical to stabilizing the patient. Furthermore, your ED diagnosis can have a profound impact good or bad on the patient's subsequent workup and care. Granted, you can't always hit a home run but I always feel a bit guilty when I have to call the admitting intensivist and say, "I don't know whats wrong with this guy but he's sicker than hell"

If you likely the cerebral side of things, think about tox after em

 

[odoreater]

Thank you ERMud/Fud, have always enjoyed your posts, was also wondering what the opinions of IM/EM in regards to the OP.

 

[GCS:3]

I worked with some of the EM/IM residents at Allegheny. They're smart as hell. Sure they're cerebral, but they can get down and dirty when it comes to trauma/etc. Some of them were looking to get jobs in hospitals where Critical Care docs work shifts (There's a movement towards this, I guess). They plan on splitting their time between ICU and ED.

 

[e2kschultz]

You'll be happier than those looking for a trauma fix. Most people only do serious trauma in residency. Afterwards if you have trauma, you call the surgeons.

Look for the more academic ER programs. Bellevue, University of Chicago, UCLA are some that come to mind. In my experience, however, 'thinking' is entirely resident and attending dependant.

I have some attendings who think over and discuss every aspect of every case, and others who say 'EM is not about thinking. It's about management.' And I'm at an extremely non-cerebral residency.

I do agree with previous posters in that you may be happier doing a medicine residency than doing ER, though. Sounds like ICU may be the place for U.

e2k

 

[odoreater]

Guess I should clarify my previous post. What intrigues me about medicine in general is diagnosing patients, I do not care to manage them. I find that diagnosing is the most exciting part of medicine. Trauma requires no diagnosis, just reaction and stabalization. So, I'd like to in essence find a program (like some of you have suggested) where I will be come an expert diagnostician (ie cerebral).

 

[The White Coat Investor]

Trauma requires no thinking....true true. Anyone ever sent someone home from a trauma without catching something? Nah...never happens. There's no thinking required. Let's see, what do you have to think about with trauma?

1) Call in the trauma team--yes or no?
2) Is the airway secure?
3) Are they oxygenating and ventilating OK?
4) Are they cardiovascularly stable? No? Why not? Bleeding, dehydrated, septic, neurogenic shock, Broken monitor, Incompetent nurse?
5) Do I need labs? Which ones?
6) Do I need a CXR? A pelvic XR? Spine films? Head CT? Belly CT?
7) Which consultants do I need now? Which ones will this patient need eventually?
8) Does this patient need an operation?
9) What does this patient need first, a FAST scan, a foley, a CXR, or a central line?

There might be more algorithms in trauma than most chief complaints, but I beg to differ with those who call it mindless. I find it much more thought-provoking than chest pain. I only have to think about one question there--is this story good enough that he needs to be admitted for a rule/out?

 

[orthoguy]

Originally posted by Desperado
Trauma requires no thinking....true true. Anyone ever sent someone home from a trauma without catching something? Nah...never happens. There's no thinking required. Let's see, what do you have to think about with trauma?

1) Call in the trauma team--yes or no?
2) Is the airway secure?
3) Are they oxygenating and ventilating OK?
4) Are they cardiovascularly stable? No? Why not? Bleeding, dehydrated, septic, neurogenic shock, Broken monitor, Incompetent nurse?
5) Do I need labs? Which ones?
6) Do I need a CXR? A pelvic XR? Spine films? Head CT? Belly CT?
7) Which consultants do I need now? Which ones will this patient need eventually?
8) Does this patient need an operation?
9) What does this patient need first, a FAST scan, a foley, a CXR, or a central line?

The above decisions can be made by a PA or nurse and certainly don't require an MD to decide. I agree with the OP, if you are going to go into EM go into somehitng that teaches you strong medicine. Trauma is for the surgeons.

 

[roja]

I tend to be with you. Trauma is not what initially drew me to ER. (I decided late in my med school career) Trauma becomes routine but it is an integral part of EM.

And even if you end up in a fancy suburban hospital, if you are the only EM and there is a trauma, its you. So trauma is important in your training. If you are in a smaller hospital, your surgeons may be at home, and level 1 means nothing if its 4 hours away.

Any ER you are going to see a diverse pathology, especially in urban cities.

I am in NYC and I see large amount of medical stuff and some trauma.

You need to be trained in it all for EM.

 

[ERMudPhud]

I've never found trauma to be very cognitively complex. You need to be conscientious and thorough. Do your ABC's, stabillize the patient, image everything you need to etc... It can be fun and rewarding but it really isn't that intellectually taxing.

The differential for the medically unstable patient is much more complex and requires much more thought if your are going to make the right decisions leading to the right interventions. Even chest pain should be more complex than deciding between admit for R/O and bullsh*t-send'em home.

You can probably ignore orthoguy's inflammatory little post. Check out his previous posts. He seems to have taken the original orthoguy's account and now posts mostly to piss people off. He hasn't said much about his background but I doubt he knows much about EM.

To the original poster: stick to your guns. It sounds like your interest in EM was much like mine and I've been very happy.

 

[odoreater]

Thank you ER MD/PHD, the list of the programs I am interviewing at is below, (in December) if you know of any that fits what we have spoken of please let me know:

Maine
U Penn
Bellvue
Jacobi
St Lukes
Mt Sinai
LIJ (EM/IM)
Christiana (Em/IM)
Denver
Cinci
Pitt
Emory

Thanks again to every poster for all of your help.

 

[roja]

odoreater I am very happy at St. Lukes. I see a huge amount of medical stuff and I feel comfortable with the amount of trauma I see. The weekly confrences are great and the 500/year of CME money we get is great. ( I got tintanalli, rosen and Wall's Emergency Airway Mgt and paid 5 bucks) We also get taken to any confrence that we have an abstract/poster accepted to. So the academics are great.

We don't do floor months. In terms of surgery, a number of second years seem to like doing a trauma surgery rotation their second year.


And I agree, EM seems right for you. You don't have to be a trauma junky to be in ER. (and I think if you are, you will probably be disappointed!)

 

[ERMudPhud]

I would put UPenn, Cinci, and Bellvue at the top of that list. I was very impressed with all three. I ended up going to Denver for a combination of personal and academic reasons. I got a great education and really enjoyed my time there. I do think it is a slightly more biased in favor of trauma though.

 

[The White Coat Investor]

Posted by MudPhud
"The differential for the medically unstable patient is much more complex and requires much more thought if your are going to make the right decisions leading to the right interventions. Even chest pain should be more complex than deciding between admit for R/O and bullsh*t-send'em home."

Agreed. The unstable medical patient is infinitely more complex than the previously healthy gangbanger with the bullet in the belly. My point was not that it was more cerebral than medical patients, but that it wasn't mindless. RE: CP It should be (more complex that is), but it oftentimes isn't. There is a lot to it, but the decision you're paid to make is: Is it safe to send this guy home with conservative treatment? (I exclude all the obvious GERD, musculoskeletal etc, I'm talking about the 59 year old smoker with diabetes who has chest pressure induced by brushing his teeth.) You have one decision to make, the rest (IV/O2/Monitor/ASA, CXR,EKG/Trop/CBC) are pretty much PA material.)

Originally posted by orthoguy
The above decisions can be made by a PA or nurse and certainly don't require an MD to decide. I agree with the OP, if you are going to go into EM go into somehitng that teaches you strong medicine. Trauma is for the surgeons.

As far as orthoguy (is he trolling today, or serious?) I propose that a PA or NP can handle any section (chest pain, abdominal pain, trauma etc) of EM quite well, but it takes an MD/DO to do it all well. By the way, when you roll in as a trauma patient, I'll just have the nurse take care of you. She's been out of college all of 2 months, but she's really good at IVs!