Counties Suck!

[The White Coat Investor]

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.

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[DrQuinn]

As the Torch from Fantastic Four used to say........... FLAME ON!

Actually I finally agree with you, Desperado. Your last paragraph would likely be the ideal situation to train.

I know at the Univ of MD, where I did a one month elective, they do the majority of their stuff at their big huge monstrous ED, but they also do quite a few months at a community ED. The majority of their patients at their main ED were very very sick indigent patients with also a few bizarro superman diseases.

Some programs I rotated at were based mainly at Level II centers that were large community hospitals. Strong bread and butter stuff, but rather bland, IMHO.

I do cringe when I hear students say that "X County Hospital" will train me to be the best. You're right about the scut work. They'll sure be busy all right. In the end, they'll pass the boards like I will...... I suppose.

I doubt we'll ever get a real objective post about the difference in training, unless we have a director of an ED here who can review the statistics for their employees and compare their residency training (which I dont' think would be THAT helpful, as I can see a huge variation in the abilities in my 6-person class at my program).

Q, DO

 

[roja]

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.

Our residency works at both a typical 'county' and a more 'private' and I think its good to see both. I also did a month at what I would consider the quientissental 'county' in NYC (Kings county).

LIke all things, there are advantages and disadvantages to each. To much time drawing blood? doesn't seem to happen to me. I help out when the nurses are swamped or when someone is a difficult stick. becasue I have had to do a number of IV's I feel reasonably comfortably trying a 'hard stick'.

I think its important to get *both* experiences. I wouldnt' feel comfortable working alone, even in a cushy hospital, if I hadn't had to run aroudn to some degree.


and now I am rambling. I think you have good points. Its not necessary to be a good doc to be at a county. but pts go to where the ambulances bring them. I have had pvts at county and vice versa.

 

[Andy Kahn]

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..

I guess the thought I had was that if I trained at a crazy place with lots of trauma and procedures, I could better adapt to "soccer mom who wants me to hurry up before their girl scouts meeting" and trying to manage my time since the "private hospital administrators above me were graphing my productivity," than if I trained at a nice suburban ED with more book reading and teaching and then had to adapt to a county facility with "GSW in room 1, MI in room 2, malaria in room 3, and a guy with malaria having an MI because he was just shot in the head in room 4 and 5." Okay, maybe a little stereotypical and over the top for those examples, but I agree with ideal program giving 1/3 of each thing you mentioned. But if I have to choose one end of the spectrum over the other, I guess I would choose the county experience to feel "overprepared" for certain things which you cannot make up for later. True, the private experience will prepare more for other things, but I think I may have an easier time adapting to the dealings with the real world. I was thinking I was headed towards a suburban private ED when I applied, but now I am leaning towards being faculty at a residency (which could still be in that environment, but I think there are more programs in the county/academic campus settings). Still, I hope to get enough experience by spending part time or a few years at various places so that I can better teach residents what they would have to do in those settings.

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.

perhaps, but at the counties i rotated at (dallas, louisville, and sacramento - which technically isn't a county anymore but the patients didn't get the memo), I only drew blood/started IVs a few times when i wanted to practice or the very rare occasion the nurses just couldnt get to it. Same with the x-ray. i did that when that was the only thing holding things up and they really needed the student to literally help move pts out the ED. (i had one faculty who apologized for me having to push a pt to radiology but I just wanted to be helpful so i didn't mind). Hehe... that bed-lock thing does make you look like a newbie volunteer if you start crashing pts into the walls.

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.

That can get frustrating. Parkland has a van that goes and picks ESRD pts up at their house so that they can get their free dialysis. Instead, they miss the van and appt so that they come into the ED dyspnic and hyperkalemic. Their visit to the ED and stay in the ICU costs more than the van/appt.

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.

Maybe someone can dispell this myth but I heard Grady at Emory was bad about this. Like I said, I felt the ancillary services at Dallas, Louisville, and Sacramento were fine when I rotated there.

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.

True. I thought it might be easier to improve upon these skills than improve upon seeing more of the penetrating trauma and very sick patients. I know that Dallas has a few months at private and community hospitals so that we can see what life is like outside of Parkland. Those few months won't be enough, but better than nothing. I also like that many of the part time faculty at Dallas work at the outside hospitals so that they can teach what would be done if there wasn't a papillary carcinoma of the thyroid fellow in house 24 hrs a day.

3) Because you are always stuck in an inefficient system, you never learn how to really practice efficient emergency medicine.

very true. Parkland is working on this. I am sure early on I will try to "clear the board" but then by my 2nd year I will get complacent and realize some people in the waiting room will still not make it back into the ED until I come back for another shift 3 days later (unless they suddenly have "chest pain" or a "seizure").

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.

ahh, but I love that about EM. besides resuscitation of the critical, we are not considered the specialist (unless we do a fellowship) so I hope to know as much as i can about the primary care tasks. well, i will complain about it as a resident no doubt, but it will only help me to be a better overall physician which is one of the reasons I chose EM, not just for the codes. Also, if a neurosurgeon comes in to do a bolt or a cardiologist comes down to transvenous pacing, I will try to learn to do that in case I ever have to get things set up or even do it if it needs to be done and they are not available (as long as I am competent and not putting the pt at risk of course). Just as many surgeons feel they are God b/c they can do surgery "and can practice 'medicine,'" I would like to be able to treat the sore throats, rashes, HTN, and diabetics along with the peritonsilar abscesses, Steven Johnsons, aortic dissections, and DKAs. Kind of lofty goals but I want to be able to provide good treatment as much as possible.

5) 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.

Am I confusing private=community/surburban
vs.
academic/university hospital/county hospital?
I understand that there is overlap and variations. Also, I know plenty of private/community/suburban hospitals are academic with a residency program but it seems you mentioned your university hospital is not considered county-like. Anyway, with the same point I made, I thought it might be an easier transition (and pleasant surprise) to shift from county to private EDs and encounter those who will follow up in contrast to training in a nice place and then having to switch over to dealing with drug addicts and the homeless.

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.

If there is a program close to that ideal (I think someone mentioned in the King/Drew thread that Maricopa incorparates some suburbia into their program. I wouldn't know, the rejected my application... but I'm not bitter) then that would be great and much less adaptation is needed after residency. However, since most are one way or the other, I hope choosing county helps me so that I "can handle anything..." well, not anything. just things that may be harder to adapt towards while allowing for gaps in areas that might not be as difficult to learn later. I guess the key is whether you know what you want to do. If you want to work in a certain type of environment, then go to that type of residency. I thought I wanted to be a community EP, but I changed my mind in the last few months. I still ranked Dallas first b/c I thought it would prepare me for the county/academic world even though I thought I would later be working in West Lake Hills in Austin, the Woodlands or Sugarland outside of Houston, Las Colinas or Lewisville outside of Dallas, or back to good old Lubbock, Texas. I also thought it would be helpful to choose that type of program just in case I later decided on working in the inner-city, gun and knife club, or whereever later and I did end up changing my mind (but it may change again!).

Please share if there are certain programs have a good mix so that future applicants can be aware of them.

Well, this is a very good topic to discuss. I agree that the county reputation may get blown out of proportion but many don't require too much scut either. i guess we use a lot of sterotypes and labels so they tend to give us a biased view, but there are some truth to them also. Definitely let me know what you think of all my rambling...

-ak (headed to county... for better or worse)

 

[Febrifuge]

I should come back to this thread later, when I'm not at my day job and can comment appropriately, but for now:

* Not all Counties are the same.
* A select few points, from Desperado and others, lead me to think some of you guys are either really at the wrong hospitals, or you're nutty nutballs, who are nuts.
* Seriously, if the docs are doing blood sticks regularly, you're working for a facility that is probably not hiring enough nurses, and definitely not hiring enough techs. It's probably appropriate for docs to feel like you do too many sticks, because it shouldn't be a regular part of your day. But you should be who we call after even the grizzled veteran RN can't hit the Amazing Disappearing Vein.
* I work at a ridiculously busy yet fancy-schmancy County, and our outgoing Year 3's are going everywhere. I cannot imagine a group that's better-prepared. If someone from our program wants to practice in the suburbs, more power to 'em.

I argue that in the 'ivory tower' world, bizarro cases are called "fascinating" or "exotic," and in the grungy, stinky County world, we tend to cluck about them being "a pity," and "waited too long to see a doctor." I'd much rather deal with someone who's really sick, even if it is their own fault, if they appreciate the help. Soccer moms also wait too long and get too sick, but their version of a sense of entitlement can be worse than that of the guy who insists on making me run for more graham crackers.

Plus, the "ready to handle anything" factor does count, if only because EM is all about people (of all kinds) and the weird crap that can happen to them. Seems to me that if a person chooses to deal with a patient population that mostly stays out of trouble, there will be less EM to be practiced. If a patient rolls in to that peaceful, gleaming suburban ER with an entire Civil War Chess Set lodged in their rectum, or a live wombat still attached to their leg, I can't speak to the response of the staff who trained in a similarly rational and normal environment, but the County-trained doc will more likely know what to do. And they'll probably feel a little nostalgic.

 

[johnson]

All I have to say is the match is a crapshoot and who knows where you'll end up. I was definately trying for a county, war zone type place but matched in an "academic" program. I'll bring the same work ethic and hardcore attitude to this program as I would if I had matched at King's. You've got to make the best of your situation and if you feel weak in a certain area find the training you need. Even if that means working in a war zone as a moonlighter or after you finish residency. Life ain't going hand everything to you on a silver platter - you've got to make it happen!!!!!!!!!!

 

[DrQuinn]

To those that think that training at county hospitals will make them "more efficient" and more proficient, I know an attending who trained at Cook County, and who sees, on average, 1.5-2 patients an hour. As an attending.

Ahem.



Q, DO

 

[Sessamoid]

To those that think that training at county hospitals will make them "more efficient" and more proficient, I know an attending who trained at Cook County, and who sees, on average, 1.5-2 patients an hour. As an attending.

Ahem.



Q, DO

Is 1.5-2 how many charts he signs, or how many patients he actually sees per hour? That's not a bad number for an academic attending to actually lay hands on, what with all the time-consuming teaching necessary.

 

[DrQuinn]

Is 1.5-2 how many charts he signs, or how many patients he actually sees per hour? That's not a bad number for an academic attending to actually lay hands on, what with all the time-consuming teaching necessary.

nope. hands on... but remember our program is so new its not really a full teaching program yet, since we're just interns and the attendings see the vast majority of hte paitents without students or residents.

Sess/ERMUDPHUD- How many patients are you averaging an hour?
Q, DO

 

[Sessamoid]

Sess/ERMUDPHUD- How many patients are you averaging an hour?
Q, DO

Depends. I'm currently working in a smaller community hospital right now, so my pts/hr is largely dependent on our overall census. However, my latest numbers are about 1.8-1.9 pts/hr not including the ones I staff with my PAs. Note also that I'm the fastest one in my group, so these numbers are not necessarily typical.

 

[DrQuinn]

Depends. I'm currently working in a smaller community hospital right now, so my pts/hr is largely dependent on our overall census. However, my latest numbers are about 1.8-1.9 pts/hr not including the ones I staff with my PAs. Note also that I'm the fastest one in my group, so these numbers are not necessarily typical.

Wow! I can't wait to be an attending!

What were you averaging at your previous employment?

Q, DO

 

[ERMudPhud]

Sess/ERMUDPHUD- How many patients are you averaging an hour?
Q, DO

Friday night I walked into the ER at 10:30 and noted a full parking lot as I walked in. My heart sank. Then I saw the full waiting room. Then I walked into the ED itself and saw the divert board showing the Level 1 center down the road on divert. I though about walking straight through to the back door and home. At 4:30 in the morning after 6 hours of running like an idiot I grabbed my stack of charts and saw that I had already seen and dispo'd 22 patients and I had another 8 patients on the board. My relief arrived at 6:00 and I left at 8:00 having seen and dispo'd 34 patients in 9.5 hours= 3.6/hour. Many of those were stupid or simple but 6 or 8 got admitted and a few were quite complicated. My PA saw an additional 10-12 at the same time. This was a bad but not the worst night I've had. I think I average around 3/hour.

 

[ERMudPhud]

I forgot to say in the response to the OP. Denver Health is a nice mix split fairly equally between County, University, and HMO/private sites. You learn very different ways of doing things at each site and I think having that exposure helps you adapt later to wherever you end up working. I think going from a county to a private or vice versa could be quite a shock otherwise

 

[DocWagner]

My residency is essentially split into level 1, level 2, and community hospitals. And while our residents enjoy the level 1's the most, when we moonlight, we slowly realize that the exposure to the community hospital setting is perhaps the most practical and allows us to be extrememly efficient.

I have found that the overwhelming majority of MI's are seen in the community setting and the weird stuff really seems to show up at the trauma centers.
I find that as I start my 3rd year that during my moonlighting shifts I can see roughly 2-3 patients an hour in the community setting without much difficulty. Last night I was able to see, clear, finish paperwork, and dispo a back boarded MVA in 15 minutes...I was done before the patient was registered.

The diverse experience allows easier transitions to different documentation types and protocol types...what is allowed in a level 1 simply doesn't fly in the community system. The community hospitals have alot to offer and you need both types of education.