Choosing a residency

[em2008]

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I would appreciate input as to how important the following factors are for EM training. Thanks!

1. Prestige of institution -- I have heard people talk about "big name programs" & "tons of resources" available at fancy academic programs, but I'm not sure exactly how that will affect me as a resident.

2. # of training sites -- Obviously the pro here is variety, but anything more than 2 sites seems like a lot of bouncing around to me.

3. Off service rotations -- I like the idea of being in the ED as much as possible, but some programs to which I applied require many off service rotations, including several ICU months plus general medicine, peds, ob/gyn, ortho, anesthesia, etc. How will this affect my training?

 

[EM_Rebuilder]

I would appreciate input as to how important the following factors are for EM training. Thanks!

1. Prestige of institution -- I have heard people talk about "big name programs" & "tons of resources" available at fancy academic programs, but I'm not sure exactly how that will affect me as a resident.

2. # of training sites -- Obviously the pro here is variety, but anything more than 2 sites seems like a lot of bouncing around to me.

3. Off service rotations -- I like the idea of being in the ED as much as possible, but some programs to which I applied require many off service rotations, including several ICU months plus general medicine, peds, ob/gyn, ortho, anesthesia, etc. How will this affect my training?

I would through 'prestige' out the window. It matters little in medicine and practically not at all in Emergency Medicine.

As far as 'Number of Sites', I would think one to two at the most. If the home institution has to farm you out to several places, then they have several voids they are attempting to fill. I think spending a month or two 'outside' is not really bad and lets you get a view of EM elsewhere (espically important if you do not or unable to moonlight). Personally, I think the 'best' program would farm you to a cush private place for a month or two, just so that you get that side of experience...its when they farm you out for more 'ICU type training' or 'trauma' that you need to be worried about.

As far as off service rotations, these are VERY important to your training. All of us in the ED like to think we are PROS at intubations, but who can really compete to the 60 yr old gas attending who has place 10,000 tubes? The idea is that you pick up a bit of his skill when you hang out with him. Personally, I think ICU months are >>>> than Floor months as you really get to learn critical care in the ICU which tends to be the more difficult side of EM. Floor tends to be filled with discharge orders, initial H&Ps, and making peoples bowels move....important, but one month of that is PLENTY. Ortho is good because you can pick up some of the little tidbits on casting and splinting that the 'pros' use. Also it can reall help hone the radiograph skills (at least it did for me).....also helped conjur up some old lost anatomy. Peds is good since its a completly different patient population that we are responsible for; again, I think a PICU month would be more important than a floor month. Many places knock OB/Gyn to one or two weeks, as you will see PLENTY of Vag Bleeding in the ED and the only real need is to help out with a few deliveries.

 

[crewmaster1]

I would appreciate input as to how important the following factors are for EM training. Thanks!

1. Prestige of institution -- I have heard people talk about "big name programs" & "tons of resources" available at fancy academic programs, but I'm not sure exactly how that will affect me as a resident.

I agree with EM_Rebuilder that prestige should be thrown out the window for the most part. However, one thing that a "big name program" or "prestigious" program can give you is alumni/connections for future jobs. One major benefit I noticed with the said to be more prestigious programs is that they tend to draw residents from a wider geographic location. A major plus is you're not sure where you want to work when you're done with residency, or if you are planning on training in an area away from where you want to practice. For example, if you train in a "small name program" that only draws residents from it's state and the bordering states, it will be more difficult (not impossible by any means) to find a top job across the country when you graduate. The "big name programs" tend to have more alumni across the country. So, if this matters to you, look at the current residents and alumni and disregard the reputation thing, but you may find they do correlate to some degree.

 

[roja]

You will generally get told to toss the 'name' issue here. I concur.

Required by RRC:
2 ICU months
1 month of ortho
OB
EMS

I can't remember if gas is required. I don't think so but its good to learn good intubation technique in a more controlled environment where you aren't worrying about aspiration, low reserves, etc. that's why gas is good.

You need peds EM experience.

Tend to agree about floor months. yes, you can learn something on any rotation. the question is what is the highest yield towards training. I tend to think you learn EM in the ED. with a couple of exceptions, which are covered by the RRC

 

[thierryh]

I think variety is important in training. Most programs try and incorporate that with at least some "private" ED experience. Gives you an idea of what things are like on the other side. You can kind of break experiences down into 1. county (indigent, underserved, govt funded, trauma) 2. university based (specialized care, transplants, some trauma) 3. private. I think ideally you'd get at least a little exposure to all three, though some university hospitals can be a little "county". You'll probably go nuts without at least a little variety, personally don't see much drawback in 3 or more different clinical settings.

From the prestige standpoint, I generally agree it shouldn't be a deciding factor, although prestige got me a job in a place where it is difficult to get a job and in a group that rarely hires people just out of residency. You'd probably do just as well training in the area you want to live in though. Whatever you do, don't train somewhere that you are pretty sure you will be unhappy just because someone told you a program is "one of the best". Interview, look around, decide for yourself.

Everyone should experience ONE floor medicine month. No more. Really only serves to broaden your exposure to what happens to the patients you admit (you can talk to your patients more logically afterward about what to expect and decide better if an admission will even serve any purpose) and sharply hone your social work skills. Any more than a month though is just to torture you and use you as grunt labor.

 

[fldreds]

On a related note...

I am interested in a couple of subspecialities (international & disaster). How important should it be for a residency to have faculty with the same interests or fellowships? (I don't know if I want to do a fellowship or not.)

Thanks!

 

[southerndoc]

On a related note...

I am interested in a couple of subspecialities (international & disaster). How important should it be for a residency to have faculty with the same interests or fellowships? (I don't know if I want to do a fellowship or not.)

Thanks!

I would say it's fairly important. Faculty with similar interests will likely have contacts at fellowship programs (probably will know the fellowship directors personally), so it would increase your chances of landing a fellowship.

 

[roja]

concur. you need to have faculty that are interested in what you are interested in. Fellowship may narrow your list of possible places but its something to definately think about. even if it doesn't land you a spot at that home institution, you need contacts. and projects to work on. As well as the possiblity of a mentor.

 

[Hard24Get]

concur. you need to have faculty that are interested in what you are interested in. Fellowship may narrow your list of possible places but its something to definately think about. even if it doesn't land you a spot at that home institution, you need contacts. and projects to work on. As well as the possiblity of a mentor.

This is becoming a critical factor for me and has broken many ties, especially since I am a weird duck, too! 👍 Nice to see others giving this advice!

What other things do applicants forget to consider? Or consider that they probably oughtn't (besides prestige)

 

[Hard24Get]

oh, and can one argue that someone primarily trained in a county environment would have a tough time dealing with an academic one, and vice versa?

 

[roja]

Those terms are pretty nebulous and ultimately pretty meaningless.

Stear clear of vague psuedo defining terms and instead ask the important questions:

How much research is done?
-how many abstracts does your hospital present?
-what support do residents have for presenting
-how many faculty do research (important if only one person is doing tons of research you won't get a diversity)

How much teaching do residents do? to whom?
How many patients do the residents see/hour?
What is the accuity?
How many presentations do the residents do?
Fellowships?
etc etc.

 

[Hard24Get]

Those terms are pretty nebulous and ultimately pretty meaningless.

Stear clear of vague psuedo defining terms and instead ask the important questions:

I guess what I meant was how important is it to see those "tertiary care" patients, etc, that people are always talking about during residency 😳

 

[roja]

What do you mean by tertiary care? Do you mean 'clinic' type stuff? I think you will pretty much see this no matter where you go. Its pretty much the state of EM and health care

 

[Hard24Get]

What do you mean by tertiary care? Do you mean 'clinic' type stuff? I think you will pretty much see this no matter where you go. Its pretty much the state of EM and health care

eh, on interviews they point out "we are a major academic center, so you get exposure to tertiary care patients", ie liver transplant pts, those weird diseases being treated at and thus present to said hospital

 

[BKN]

eh, on interviews they point out "we are a major academic center, so you get exposure to tertiary care patients", ie liver transplant pts, those weird diseases being treated at and thus present to said hospital

Well, i love both primary and tertiary kinds of care. I think having both is ideal. But if i had to pick one, I'd go for the county. After all, the tertiary patients always have tertiary docs. And the treatment of transplant emergencies in the ED is pretty simple: 1. Collect data 2. DON'T CHANGE ANY MEDS!!! 3. Call their doctor.

 

[roja]

Well, i love both primary and tertiary kinds of care. I think having both is ideal. But if i had to pick one, I'd go for the county. After all, the tertiary patients always have tertiary docs. And the treatment of transplant emergencies in the ED is pretty simple: 1. Collect data 2. DON'T CHANGE ANY MEDS!!! 3. Call their doctor.

I tend to agree with BKN. tertiary's are interesting because they trigger in many of us the 'coolness' factor... they have wierd diseases on complicated meds that we know little about. So, the stimulate the brain. But the real management? I think BKN has it on spot: get labs, dont change anything and call thier doctor.

As an ED doc, you arent really going to be 'managing' these patients. Maybe they are crashing but a crashing tertiary patient is pretty much a crashing patient. the tertiary part becomes secondary and your primary concern is resusc. (I really just wanted to see how many numbers I could get in that sentence.)

Like all things, you can learn from it. Does it mean if you don't see it you can't go anywhere else? or that if you see it, you can't go private?

not at all. there is great mobility in EM. period. You will get good training. figure out what is good for you: location, personality, general interests.