County residency => community job

[DOmergency]

Wayne State/ Detroit Recieving is an AMAZING program, absolutely loved the loads of crazy stuff that go down in their ED. Easily in my top three programs for residency.

Only problem is that I'm headed for a less intense community practice afterward, given that just about every other place in the country isn't about to average three cracked chests a month. I was talking to a local doc who does the hiring for his group who flat out said he wouldn't ever hire a Detroit graduate.

Said the county experience there wouldn't prepare me for moving the meat in a less acute setting, that they'd have to retrain just about most my decision making practices.

Is this the case? Are county grads less desirable for community jobs?

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[Interpolfanclub]

Disagree. I went to a county program and am practicing in the community. County programs see really sick people and you do tons of procedures. This prepares you for any practice environment. The only thing I think county programs don't do as well as more community programs is the customer service aspect of EM, which is HUGE now. But that can be learned. What you don't want to be learning out in practice is how to put in that difficult line or LP and having to get your partner to try etc etc while the waiting room backs up. If anything county programs from my point of view, made me more efficient because I'm no longer pushing people to xray, making some of the beds, etc. This idea that somehow county grads won't make good community docs is something I've heard for a while but haven't seen much evidence for.

 

[Venko]

I personally don't believe that any program will train for every environment. There will be a lot of retraining when you step into a different setting or different hospital.

Community practice can be vastly different from county practice. The patients come with different expectations. Some places, waiting five minutes in the waiting room is considered an inconvenience. Some community programs service a different kind of sick than what traditional county program see.

Many county hospitals will see very severe diabetic complications, or MIs, or another single disease to the extreme, where as some other hospitals have sick patients who have problem lists that are 12 or 13 long that all interplay. Other hospitals have more transplant focuses, or do more unique surgical procedures.

I personally, view choosing a residency as a decision that should match where you plan to practice after you are done. Obviously there are exceptions and there are great community ED docs who train in county programs, and great community trained ED docs who practice in county programs, and most of us can learn to practice in a different setting, but there is a learning curve. There is "retraining" involved that will vary based on the background of the physician.

TL

 

[EctopicFetus]

On a similar note.. Working in the community involves more Press-Ganey, patient satisfactoin, dealing more with admin / limited resources.

I trained at an academic spot and one of the hospitals we spent ~25% of our time was county-esque.

I can tell you the community is very very different. Different patients, different problems etc.

Also keep in mind in a major place you will have every consultant you can imagine whereas in some smaller community hospitals things are very different and for better or worse things are done certain ways there.

 

[DOmergency]

Thanks all! That's more or less what I had been thinking. I was just taken aback by the force of this guy's reaction. Maybe he had had a bad experience with one Recieving grad in the past. Who knows, go figure.

 

[bartleby]

Look, people who train in a county program are used to working in a resource austere environment and tend to be quite adaptable. Folks who go into emergency medicine tend to be less of the Prima Donna type in the first place, and can deal with whatever life throws at them in general. However, there can be quite an adjustment between working in a place where getting someone admitted involves calling the medicine admitting resident and saying, “Hey, I got a guy here with pneumonia. Come get 'em!" as opposed to having to negotiate an admission between the hospitalist, pulmonology and cardiology.

Furthermore, docs in a community Hospital who have adequate ancillary staff and nursing support will see many, many more patients in a shift than the average resident who only sees a relative few patient because they have to do the bloods, the EKG, the Foley and wheel the patient back and forth to CAT scan. This part, in particular can be a real shocker.

When you are the doc in a community ED, you're there to do two things: to make patients happy and to move the meat.

 

[Arcan57]

Ideally, your residency will feature elements of both community and county aspects. Sometimes these are the same hospital (where the inner-city hospital is also the tertiary-care referral center), sometimes it will be having rotations in outside hospitals with a different feel. The changes in the community from a county atmosphere are not insurmountable. If the community hospital has a bunch of high-maintenance, high-volume consulting/admitting dotors or a particularly entitled patient population, it may not be worth it to the director to deal with the complaints that a new grad from a county program will create.

 

[la gringa]

trained at a county place, went to a pretty high maintenance community spot for my first job. a hybrid is probably best.... hate the butt kissing and move the meat mentality. i like to take good care of people and look out for the little guy.... not always popular in some spots.

 

[corpsmanUP]

This is an amazingly important topic. I hope it gets more reads from the senior residents. I started a topic recently on "Missing Academics Yet" which was sort of similar.

I could not agree more with the above comments on the differences between community and county hospital practice. I personally feel that we should do more to prepare residents for community practice. It's not being prepared for the acuity that is the difficult part, but instead preparing for the other obstacles to good care such as:

-Ridiculously ambiguous objectives of patient satisfaction and efficiency
-Often less helpful consultants
-less availability of specialists on a consistent basis
-the frustrating need to transfer so many patients
-nursing confusion over modern practice techniques
-lack of good support from the secretary to the nurses
-colleagues that may not be as well trained
-the above line which makes signouts more dangerous/uncomfortable
-the realization that some of the worst doctors have the highest patient satisfaction scores..because they have learned how to play the system. They give pain meds to everyone..mostly the addicts, and they order x-rays on every injury, antibiotics to every laceration and pedi URI, and they basically have laid down and given up on trying to practice any sort of evidence based medicine.
- nursing directors that often make changes without consulting with you
(just last month my airway carts were taken out of the department, and all the airway equipment replaced with cheap plastic laryngoscope blades and dumped into a gray box like some grab bag...their rationale was...we need the carts for "other things")
- Administration that has no worries about implementing things like medical screening exams and placing all liability on you when a midlevel sends away someone from triage who actually ends up having something wrong.....but the screening criteria was met!!!

On a bright note, if you can tolerate all the above issues, you can exist in the community and make BIG MONEY. Easy to make 350-450K where I live, but of course it's like selling your soul to the devil!!

 

[Venko]

This is an amazingly important topic. I hope it gets more reads from the senior residents. I started a topic recently on "Missing Academics Yet" which was sort of similar.

I could not agree more with the above comments on the differences between community and county hospital practice. I personally feel that we should do more to prepare residents for community practice. It's not being prepared for the acuity that is the difficult part, but instead preparing for the other obstacles to good care such as:

-Ridiculously ambiguous objectives of patient satisfaction and efficiency
-Often less helpful consultants
-less availability of specialists on a consistent basis
-the frustrating need to transfer so many patients
-nursing confusion over modern practice techniques
-lack of good support from the secretary to the nurses
-colleagues that may not be as well trained
-the above line which makes signouts more dangerous/uncomfortable
-the realization that some of the worst doctors have the highest patient satisfaction scores..because they have learned how to play the system. They give pain meds to everyone..mostly the addicts, and they order x-rays on every injury, antibiotics to every laceration and pedi URI, and they basically have laid down and given up on trying to practice any sort of evidence based medicine.
- nursing directors that often make changes without consulting with you
(just last month my airway carts were taken out of the department, and all the airway equipment replaced with cheap plastic laryngoscope blades and dumped into a gray box like some grab bag...their rationale was...we need the carts for "other things")
- Administration that has no worries about implementing things like medical screening exams and placing all liability on you when a midlevel sends away someone from triage who actually ends up having something wrong.....but the screening criteria was met!!!

On a bright note, if you can tolerate all the above issues, you can exist in the community and make BIG MONEY. Easy to make 350-450K where I live, but of course it's like selling your soul to the devil!!

Well said!

 

[jdawson12]

This is why I recommend the community academic programs that still have a strong county experience like Christiana Care, Carolinas etc

These places take care of the indigent population but also the howty towty populations. Treating a homeless uncontrolled non compliant diabetic is very different than treating a well controlled multimillionaire diabetic. The disease processes are different, the interactions with each patient are different and the approach to each patient is vastly different.

I think this is a weakness of the typical county hospitals that only do one month, or a one shift a month at a community hospital.

 

[Venko]

Treating a homeless uncontrolled non compliant diabetic is very different than treating a well controlled multimillionaire diabetic. The disease processes are different....

Am I missing text based sarcasm?

Diabetes is different in these two patients?

I have taken care of both given my residency was at Mayo Clinic and now I work in an inner city ED and a VA ED...I would disagree that the disease processes are different...insulin, fluids, and potassium all seem to work just as well on both groups.

The patient care interactions, resources, and knowledge of your ancillary staff all are different, but the individual disease is the same. At mayo though, it was a much more intricate constellation of medical problems with glycemic dyscontrol on top of it....

 

[la gringa]

entitled, rich people get DKA, hyperkalemia, etc from diet and med noncompliance too!

 

[gizmo007]

I am hoping that some attendings or senior residents can comment on this issue. From all your years of experience, do you feel that graduates that trained at a place like cook county, king's county, lincoln, detroit receiving, henry ford, and similar programs will have difficulty in getting a job in some community/university hospitals?

 

[la gringa]

I trained at one of the programs mentioned by gizmo (the one w/ the best reputation IMHO!) and most people do community... all of my classmates went to the city/region of their choice and didn't have a lot of trouble doing so. some cities are tough for anyone fwiw... but no issues for my class or the ones just before/after mine.

 

[jdawson12]

Am I missing text based sarcasm?

Diabetes is different in these two patients?

I have taken care of both given my residency was at Mayo Clinic and now I work in an inner city ED and a VA ED...I would disagree that the disease processes are different...insulin, fluids, and potassium all seem to work just as well on both groups.

The patient care interactions, resources, and knowledge of your ancillary staff all are different, but the individual disease is the same. At mayo though, it was a much more intricate constellation of medical problems with glycemic dyscontrol on top of it....

You need to different treatment from disease process.

Diabetes is very different in the two individuals I described. The treatment for the disease processes are the same of course, but different disease processes dominate in each population. The homeless uncontrolled diabetic is more likely to have DKA, peripheral vascular dz, diabetic foot ulcers, etc. While the well-controlled diabetic who has all the proper means to control their diabetes is less likely to have these hyperglycemic complications (than the uncontrolled diabetic) and are more likely to present with hypoglycemic complications from too tight of control of their diabetes, or Renal tubular acidosis from metformin or P-par induced cardiomyopathy.
I am not saying that these rules are definite (they are far from it), but if you only see one population you may be missing out on the different diabetic processes that can occur.
Please do not infer from this that poor = noncompliant or that rich = compliant. Understand that I mean that the means available to the two different popultions change what treatment options are available and therefore the disease process but NOT the disease treatment.

The same reasoning can be extrapulated to other disease processes

You treat a 48 low-moderate risk Chest pain pt with poor follow up differently than you do one with the same story who is best friends with the cardiologist and can been seen in his office the next day.

 

[corpsmanUP]

You need to different treatment from disease process.

Diabetes is very different in the two individuals I described. The treatment for the disease processes are the same of course, but different disease processes dominate in each population. The homeless uncontrolled diabetic is more likely to have DKA, peripheral vascular dz, diabetic foot ulcers, etc. While the well-controlled diabetic who has all the proper means to control their diabetes is less likely to have these hyperglycemic complications (than the uncontrolled diabetic) and are more likely to present with hypoglycemic complications from too tight of control of their diabetes, or Renal tubular acidosis from metformin or P-par induced cardiomyopathy.
I am not saying that these rules are definite (they are far from it), but if you only see one population you may be missing out on the different diabetic processes that can occur.
Please do not infer from this that poor = noncompliant or that rich = compliant. Understand that I mean that the means available to the two different popultions change what treatment options are available and therefore the disease process but NOT the disease treatment.

The same reasoning can be extrapulated to other disease processes

You treat a 48 low-moderate risk Chest pain pt with poor follow up differently than you do one with the same story who is best friends with the cardiologist and can been seen in his office the next day.

I just think your logic is weird. I hear what you are saying; I just can't agree.

 

[Venko]

You need to different treatment from disease process.

Diabetes is very different in the two individuals I described. The treatment for the disease processes are the same of course, but different disease processes dominate in each population. The homeless uncontrolled diabetic is more likely to have DKA, peripheral vascular dz, diabetic foot ulcers, etc. While the well-controlled diabetic who has all the proper means to control their diabetes is less likely to have these hyperglycemic complications (than the uncontrolled diabetic) and are more likely to present with hypoglycemic complications from too tight of control of their diabetes, or Renal tubular acidosis from metformin or P-par induced cardiomyopathy.
I am not saying that these rules are definite (they are far from it), but if you only see one population you may be missing out on the different diabetic processes that can occur.
Please do not infer from this that poor = noncompliant or that rich = compliant. Understand that I mean that the means available to the two different popultions change what treatment options are available and therefore the disease process but NOT the disease treatment.

The same reasoning can be extrapulated to other disease processes

You treat a 48 low-moderate risk Chest pain pt with poor follow up differently than you do one with the same story who is best friends with the cardiologist and can been seen in his office the next day.

I'm not sure I agree since the majority of DKA and HHS are triggered by an infection or other inciting event, they occur in both populations with relative frequency....is there a subtle but significant difference, I will defer to you if you have actual numbers, but the disease process / pathophys is identical and I'm sure that both county and community practitioners will see and gain comfort with both sets of complications...just my opinion.

 

[epiepishockMD]

Instead of making a new thread I thought I would bump this one.

I am thinking about doing the opposite. Trained in a high volume tertiary care academic/community style medical center (ie, all the specialists essentially in house, STEMI center, stroke center, trauma center, etc).

How unwise would it be for me to take my first job in a less supported county hospital. I feel ready, pretty sure i'm not at the beginning part of the curve.

 

[littlejuan]

One thing to think about Detroit Receiving is that you are not just at Receiving but you also work a decent amount of shifts at Harper Hospital and Huron Valley which is a community hospital in the suburbs. So it really is a bit of a hybrid program more than anything.

EDIT

Oh, the OP is a few years old.


Anyway, I trained at a county program and had no trouble adjusting to a community job.

 

[RoyBasch]

This is an amazingly important topic. I hope it gets more reads from the senior residents. I started a topic recently on "Missing Academics Yet" which was sort of similar.

I could not agree more with the above comments on the differences between community and county hospital practice. I personally feel that we should do more to prepare residents for community practice. It's not being prepared for the acuity that is the difficult part, but instead preparing for the other obstacles to good care such as:

-Ridiculously ambiguous objectives of patient satisfaction and efficiency
-Often less helpful consultants
-less availability of specialists on a consistent basis
-the frustrating need to transfer so many patients
-nursing confusion over modern practice techniques
-lack of good support from the secretary to the nurses
-colleagues that may not be as well trained
-the above line which makes signouts more dangerous/uncomfortable
-the realization that some of the worst doctors have the highest patient satisfaction scores..because they have learned how to play the system. They give pain meds to everyone..mostly the addicts, and they order x-rays on every injury, antibiotics to every laceration and pedi URI, and they basically have laid down and given up on trying to practice any sort of evidence based medicine.
- nursing directors that often make changes without consulting with you
(just last month my airway carts were taken out of the department, and all the airway equipment replaced with cheap plastic laryngoscope blades and dumped into a gray box like some grab bag...their rationale was...we need the carts for "other things")
- Administration that has no worries about implementing things like medical screening exams and placing all liability on you when a midlevel sends away someone from triage who actually ends up having something wrong.....but the screening criteria was met!!!

On a bright note, if you can tolerate all the above issues, you can exist in the community and make BIG MONEY. Easy to make 350-450K where I live, but of course it's like selling your soul to the devil!!

Any graduating senior resident should be reading this post carefully.

 

[The White Coat Investor]

Is this the case? Are county grads less desirable for community jobs?

Yes. But that retraining doesn't take that long. It's mostly customer service kind of stuff which isn't that tough.

We have a number of county grads and they do just fine.

 

[surely]

Yes. But that retraining doesn't take that long. It's mostly customer service kind of stuff which isn't that tough.

We have a number of county grads and they do just fine.

What kind of things do you have to retrain academic and community grads on, compared to their county grad colleagues? Trying to discern the benefit of county training, if such a thing exists.

 

[The White Coat Investor]

The main benefits of county training are high acuity, lots of procedures, and a broad scope of practice compared to an ivory tower. The ivory tower tends to get the weird stuff- sick congenital kids, transplant kind of stuff etc. Community would probably be a little more ready for the actual practice of community EM.

The main issue with county folks is they show up and act like they're doing the patients a favor and that the patients have nothing to do with their retirement, their vacations, and their kids going to college. They also don't realize that a lot of things are better done in clinic the next day than admitted to the hospital. It's like they're amazed when they find out some people have insurance and real primary doctors who will see them the next morning.

 

[littlejuan]

.

 

[chillaxbro]

What defines county? How is it different than community?

 

[suckstobeme]

The main benefits of county training are high acuity, lots of procedures, and a broad scope of practice compared to an ivory tower. The ivory tower tends to get the weird stuff- sick congenital kids, transplant kind of stuff etc. Community would probably be a little more ready for the actual practice of community EM.

The main issue with county folks is they show up and act like they're doing the patients a favor and that the patients have nothing to do with their retirement, their vacations, and their kids going to college. They also don't realize that a lot of things are better done in clinic the next day than admitted to the hospital. It's like they're amazed when they find out some people have insurance and real primary doctors who will see them the next morning.

WCI probably has more experience with new grads from various programs showing up to work at Community ER and being aloof or whatnot, but I would hope the majority of county grads figure out that your patient is also your customer and act accordingly. I like to think I wasn't like that when I first started. However, I absolutely was amazed when people could see a PCP the next day.

That all said, I went to a County Program and currently work in the Community and I would say it was an easy transition. The nurses are better, often times techs do your splints and lacs, specialists are more willing to help you out, more toys (MRI), easier admits, etc. In my county residency, drawing your own blood and doing your own IV was not that uncommon. Coming from a county place, I think you do a lot of stuff yourself that someone else might consult, and for that reason alone I'm glad I did County -> Community and not the other way around. I've found that some of the hardest places to train are actually University Programs because you often give up experiences to other specialty residents. Some university programs/attendings have a culture of every peritonsillar needs ENT, every dental abscess needs oral surgery, every hip dislocation needs Ortho, etc. All those guys are just sleeping upstairs anyway, so why not? I was just reading the ACEP throwaway newsletter and there's a Hand Surgeon that complained that ED residents at his University Hospital call ortho residents for paronychias. I think in the community there's an expectation that you handle a lot of that yourself, though certainly that varies from place to place.

The big downside coming from a county place is that often times people don't care about charting/billing. We had 1 lecture in my last yr about how to chart a level 5 chart and why that's important vs a level 3 chart. Also, some county places are hard to sue for malpractice (not entirely sure why) so there's less "defensive charting" done, so when you leave you have to figure out how to do that. Community places seem to stress good charting habits from the get go. Certainly not unlearnable, but I definitely chart a lot different from what I did in residency.

Of course, all programs are different and certainly there are going to be County places with resources and good charting habits and University places that have a do-it-yourself attitude.

 

[The White Coat Investor]

What defines county? How is it different than community?

A county program is like Cook County or USC or Harbor-UCLA or Parkland or Hennepin. We've got Parkland and Hennepin grads in the group and they do fine, but there's a bit of a customer service learning curve those first few months. It's particularly steep in Utah where EM is a super competitive business.

Military docs may have a similar outlook to people who trained at a county place- i.e. no need to keep the patients happy, they don't have anywhere else to go.

 

[RustedFox]

A county program is like Cook County or USC or Harbor-UCLA or Parkland or Hennepin. We've got Parkland and Hennepin grads in the group and they do fine, but there's a bit of a customer service learning curve those first few months. It's particularly steep in Utah where EM is a super competitive business.

Military docs may have a similar outlook to people who trained at a county place- i.e. no need to keep the patients happy, they don't have anywhere else to go.

Not long ago I worked with a PA who worked primarily in the military for the first few years of his career. "We" were his first "community" job.

Took him awhile to figure out that the average patient here on the gulf coast of FL was a medically complicated 65+ year old, and that not every patient was an otherwise healthy 20-something.

"Duuude... you can't just throw 60mg Toradol and 20mg Reglan (yes, 20 mg) at the 67 year old with the worst headache of her life. Twice. ... You gotta work these people up."

 

[BoardingDoc]

That all said, I went to a County Program and currently work in the Community ... often times techs do your splints and lacs

Wait, what? Splints, yeah but you have techs doing your lacs???

 

[The White Coat Investor]

Wait, what? Splints, yeah but you have techs doing your lacs???

The techs did the lacs in the military, but I've never seen one do one in a civilian ED.