Okay, okay, simmer down you county folk. That was just an inflammatory title to get you in the thread. The bone of contention that I wish to toss out is this: I frequently hear this idea that "once you've trained at a county hospital ED you're prepared to do anything in EM" or "you can handle anything" or "you've seen it all." It seems to me this idea isn't entirely correct for a number of reasons. First, the disclaimers. I think you will have the opportunity as a medical student and as a resident to do more procedures at a county hospital. Unfortunately, the procedures will sometimes include drawing blood, starting IVs, wheeling patients to X-ray (I tried it once, it can be hard until you get the hang of that bed-lock thing,) etc. A county hospital will also provide the opportunity to see disease that has progressed farther than it should have before being seen by a physician. I guess seeing the natural process of a disease can be somewhat educational. Being at a county also allows one to help those who most need help and provide for those who have nowhere else to go. I also must admit that when shopping for EM residency programs I was hoping to go to a program that provided both an ivory tower and a county experience, but ended up sacrificing that to get some other things I wanted (a nice location, fun people to work with etc.) Now that I've shown you I'm not just Mr. Anti-County, here are my points for discussion: 1) Because you have to draw blood etc. you spent less time doing things you need to be learning how to do. More scut=less education=crappier physician. 2) Because all of your patients come from one socio-economic class (uhhh...the lowest one, whatever that is) you never learn how to communicate with and practice medicine on the average, the rich, the educated etc. 3) Because you are always stuck in an inefficient system, you never learn how to really practice efficient emergency medicine. 4) Because your patients have nowhere else to go, you have to do a higher percentage of primary care tasks than you would at another facility. I'm currently working at a university hospital (which has its own problems, don't get me wrong) and it seems to me I still see plenty of "county-type" patients to learn on, but I also learn how to treat people who can see their PCP in 2 days, who understand discharge instructions, and who have a clean tox screen. I feel like I've got plenty of procedures under my belt and at the end of my intern year am more than willing to start giving them away. I also feel like I've seen as many "drunk, abusive, burdens on society" (not my words) as I need to to learn their unique health care problems. I propose that the ideal program to learn to practice EM is the one most like the job you will take after you are done with residency. But since few of us know exactly what that will be, it is the program which provides the most variety. I would think it would be ideal to spend 1/3 of your time doing efficient, bread and butter community EM, 1/3 of your time seeing the ivory tower transplant/trauma/bizarro diseases, and 1/3 of your time at a county. I don't think once you've been to a county "you can handle anything." Okay, let the flaming begin.