County style residency programs

[Venko]

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Alternatively:

A nursing home resident with a chief complaint of "fever" who can't give a history, so all you have to do is review a med list, check applicable drug levels (salicylate, digoxin, valproate, etc), order a CXR, perform a particularly easy intubation and follow it with a CVL on someone with easily identifiable landmarks, start the standard antibiotics, follow up on said labs, and admit to the MICU.

Now which one sounds like the more difficult patient?

I'm not saying that the answer is clearly that trauma is harder than medical - I'm saying that it's absolutely not clear.

Wilco, why are you checking these drug levels for fever? Did you consider hyperthyroidism before antibiotics? Considering Urinalysis, abdominal infection, and looking for Fournier's should also be considered. Assessing for NMS, serotonin syndrome would not be unreasonably based on the chief complaint of fever in a NH patient. My initial reaction to this is that your description here falls way short of making your point that everyone understands the workup of fever in the NH patient.

 

[WilcoWorld]

Thymeless, I think you misunderstood me.

I was not advocating for the approach I described, I was trying to make a point; That if you approach trauma mindlessly (just follow ATLS), your management will be mindless. By the same token, one can approach NH patients with a fever mindlessly (just order labs, start antibiotics +/- EGDT & admit), and their management will be equally mindless.

It bothers me that people compare a thoughtful approach to medical patients to a thoughtless approach to trauma and thus conclude that trauma is easy. If one thinks that the mindless application of ATLS will suit all trauma patients equally well, then that person has an incomplete understanding of trauma care.

 

[Powdermonkey]

So, I've been reading along with the responses here, and I think that this discussion is one I've been trying to have with a number of people for a while. The problem is I'm either at a county place, or an academic place or a community place. Never with attendings and residents of each style together. So I really only get one side of the puzzle at a time. I really like where this is heading, so please, keep going.

People that want county want high intensity, craziness, and often intense trauma. All the bread and butter stuff is available anywhere.

....

See, that's what I was thinking I wanted. It's what attracts me to the county programs at least.

This is an excellent point. Your resources really affect what treatments are actually feasible in the ED. Got a bad beta blocker overdose and want to use hyperinsulinemic euglycemia therapy? Well, I hope you only have one patient so you can be drawing those frequent blood gases and doing fingersticks.
In my ED you can really rely on the nurses to be on their A-game, drawing labs, monitoring drips etc. I can see a hell of a lot more patients in a shift than I could a lot of other places because I have nurses and ancillary services I know I can count (usually) on.

Good point.

...at least from my experience...

County is good for trauma, but not great for the private world. Some have a mixed shop (county that also covers the well insured), it seems to help in that you get used to working with private attending from all specialties, get the K+G club, and the high rollers who come in with their own private MD meeting them there.

In private you don't see too much trauma, but you do see a lot of bread/butter with usually NO sub specialists "in house", as opposed to county/residency/big programs where you have a vascular fellow/cath lab/optho all in house.

Learning to manage those types of patients and knowing what to do WITHOUT a sub-specialist immediately on call is a good thing to have coming out of residency.

Clinically as well as "ancillary support" is vastly different between the two. In retrospect (med school at Cincy, residency at Carolinas, split work 30hr/mo private group, and 130hr/mo with Carolinas) I don't see much appeal in a pure "county" setting.

This is exactly what I want out of a residency program.

I really think that I'm not sure what I want in a program now. I was of the opinion that I wanted a "county" type program, but I had never really experienced anything different until this month. I'm at a pretty academic program this month and I have to say, I'm really enjoying myself. The attendings and residents have been awesome, and it's been busier than I quite expected to be honest. I've seen everything from burns to scrofula from miliary TB and almost everything in between. I was thinking that being at an academic place meant that the ER was gonna be girly and not see very much, but the same crap comes in here as did the county place I was at last month.

The more I talk to the residents, the more I can see a difference in lifestyle between the two places. It almost seems like at the county program they are working their asses off and don't really get much in the way of free time. At the academic program this month, the residents seem to have a slightly better lifestyle as well as more EM months in their schedule for all 3 years.

You get enough trauma everywhere you go.
I would rather go somewhere without a lot of trauma as I don't want to live or work somewhere I'm likely to get shot or assaulted walking to the parking lot.

Not all residencies are equal, but just because you can handle trauma doesn't mean you can handle everything. There is no thought process to ATLS, it is completely algorithm driven.

Good point that I've not really put much thought to before now...

This raises and interesting question. What makes a county shop a county shop?

Calahin is defining a county shop by the lack of services, equipment, etc. Others might define county by the population or the pathology. For others it might be geography. For administrators it's all about financial structure (i.e. only a publicly funded hospital is county).

I was thinking more of the population and pathology. But I'm not sure that if all you see is the poor and underserved population you're going to get the best and broadest education during residency. If all you are doing is tubing and putting in central lines and admitting, then you're not really learning how to workup and treat those super sick patients.

.....

One last point, this time regarding picking a residency: Choose based on what kind of EM you want to practice when you are finished. If you are going to be hard-core research, pick a place that will support that. If you are going to be an urban, county doc, train at county. If you are going to be a small community doc pick a community program (or - IN MY OPINION ONLY - hard core county - as a lot of those community docs are left all on their own with little support and have to be able to do everything, like EM docs at county do).

When in doubt, try to see it all and do it all...where that best experience is, no one knows.

HH

I'm interested in being a community doc that still teaches. Working at a huge county or academic level 1 for the next 25 years really gets me excited. I want to get out there and work some and then get back in to teaching and taking students. If that means working a few shifts a month at an academic or teaching facility I can handle that. Which leads me back to what type of program do I want to train at, and what is going to work best for me. Talking with some of the residents this month and a few of the attendings, I've come to realize that I'm going to be pretty well prepared for private practice and working out on my own no matter where I go.

I want to be able to handle the sickest of the sick. Trauma will come. Whether it's in the first month or the first year, I'm not really worried about it. I'm not sure that I'll be working at a dedicated trauma center when I get out, so it's something that I want to be adept at and be able to handle. But I'm not going in to residency to be a trauma surgeon, or trauma specialist. I completely agree that the sick multiply comorbid medical patients are exponentially tougher to manage and deal with than the trauma patient. That's what I want to get proficient at.

I thought I had my application list all figured out until you guys started with this discussion. I think it's going to be much more of a mix of programs now. I blame you.

 

[Venko]

Thymeless, I think you misunderstood me.

I was not advocating for the approach I described, I was trying to make a point; That if you approach trauma mindlessly (just follow ATLS), your management will be mindless. By the same token, one can approach NH patients with a fever mindlessly (just order labs, start antibiotics +/- EGDT & admit), and their management will be equally mindless.

It bothers me that people compare a thoughtful approach to medical patients to a thoughtless approach to trauma and thus conclude that trauma is easy. If one thinks that the mindless application of ATLS will suit all trauma patients equally well, then that person has an incomplete understanding of trauma care.

I get your point, I missed it before.. I dont quite agree, but I get what you're trying to say.

 

[Arcan57]

Every EM resident (excepts the fools that got suckered in by the "lifestyle" pitch) want to take care of sick/dying patients and to get good at dealing with the critical. Every EM residency is going to teach you how to take care of the sick and dying patient, but there are going to be differences depending on hospital factors and specialty availability.

You absolutely have to be able to stabilize any patient that is salvageable, but after that the "right" thing to do is going to be hospital dependent. Take DKA for example. At my med school (major county shop), the right thing to do was to continue ordering the alternating q1h VBG and lytes, titrating the insulin drip, repleting lytes, and the patient would usually have their gap cleared and be off the drip before an ICU bed opened up. In residency, the right thing to do was to get the patient stabilized, get a set of repeat labs to make sure the patient still needed the ICU, and then admit. In my first community job, the right thing to do was to identify the patient was in DKA and immediately call the intensivist to work on an ICU bed.

Calling immediately helped me out because it reduced my workload and it helped the patient out because, with a minimum of 4:1 pt-nurse ratio, if I could get q4hr labs done it was a major coup. Of course from the academic side it's easy to cast stones about "not managing the patient", while from the community side it's ridiculous to spend 2 hrs of time on 1 patient when you have 20 waiting to be seen. County shops will typically have higher work/pt loads, but if you look at pts/hr the inefficiencies in the system will cause high turn-around times and you'll probably see fewer patients than a community shop. Both approaches are adaptive to their environment, but if a program skews heavily towards one side it's going to be difficult to practice in the opposite environment coming out of residency.

 

[Venko]

Every EM resident (excepts the fools that got suckered in by the "lifestyle" pitch) want to take care of sick/dying patients and to get good at dealing with the critical. Every EM residency is going to teach you how to take care of the sick and dying patient, but there are going to be differences depending on hospital factors and specialty availability.

You absolutely have to be able to stabilize any patient that is salvageable, but after that the "right" thing to do is going to be hospital dependent. Take DKA for example. At my med school (major county shop), the right thing to do was to continue ordering the alternating q1h VBG and lytes, titrating the insulin drip, repleting lytes, and the patient would usually have their gap cleared and be off the drip before an ICU bed opened up. In residency, the right thing to do was to get the patient stabilized, get a set of repeat labs to make sure the patient still needed the ICU, and then admit. In my first community job, the right thing to do was to identify the patient was in DKA and immediately call the intensivist to work on an ICU bed.

Calling immediately helped me out because it reduced my workload and it helped the patient out because, with a minimum of 4:1 pt-nurse ratio, if I could get q4hr labs done it was a major coup. Of course from the academic side it's easy to cast stones about "not managing the patient", while from the community side it's ridiculous to spend 2 hrs of time on 1 patient when you have 20 waiting to be seen. County shops will typically have higher work/pt loads, but if you look at pts/hr the inefficiencies in the system will cause high turn-around times and you'll probably see fewer patients than a community shop. Both approaches are adaptive to their environment, but if a program skews heavily towards one side it's going to be difficult to practice in the opposite environment coming out of residency.

Very well summarized.

 

[deleted65604]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

All procedures would therefore, go to ER residents. Anesthesia rotations would be designed simply to give massive numbers of intubations to ER residents. Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't). Trauma wouldn't be a big stupid gawk-fest with 2 medical students, 2 ER residents, 2 surgery residents, and a gaggle of pharmacists/nursing students, etc., let alone the legitimately needed nurses and techs necessarily involved. All hospital codes would be run by ER residents that come up from the ER. ICU rotations would be an unadulterated procedure-fest. Could it exist? Would you agree? Why, why not?

 

[Dwindlin]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

All procedures would therefore, go to ER residents. Anesthesia rotations would be designed simply to give massive numbers of intubations to ER residents. Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't). Trauma wouldn't be a big stupid gawk-fest with 2 medical students, 2 ER residents, 2 surgery residents, and a gaggle of pharmacists/nursing students, etc., let alone the alegitimately needed nurses and techs necessarily involved. All hospital codes would be run by ER residents that come up from the ER. ICU rotations would be an unadulterated procedure-fest. Could it exist? Would you agree? Why, why not?

Sweet merciful christ this would be awesome

 

[deleted109597]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

All procedures would therefore, go to ER residents. Anesthesia rotations would be designed simply to give massive numbers of intubations to ER residents. Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't). Trauma wouldn't be a big stupid gawk-fest with 2 medical students, 2 ER residents, 2 surgery residents, and a gaggle of pharmacists/nursing students, etc., let alone the alegitimately needed nurses and techs necessarily involved. All hospital codes would be run by ER residents that come up from the ER. ICU rotations would be an unadulterated procedure-fest. Could it exist? Would you agree? Why, why not?

It does exist in a few places. I interviewed at one way back when and didn't go there.

That being said, some of the things could be done at level 1 sites with more stuff.
I trained at a level 1, but plenty of the trauma call nights were EM seniors and EM juniors running the team, with a chief in house if they wanted to operate. Otherwise, it was all ours. Similarly, the ICU was run by us, because the medicine residents and ICU fellows were all, frankly, idiots. We didn't have a gas residency, but we did have a CRNA training center, so they got all the tubes, and our anesthesia/skills month was worthless.

 

[MSmentor018]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

I know a few community places like that but of course the acuity is very low. I am at a level I and we have 1,2,3 (partial) checked off but the 4th one.....they can be a pain in the ass sometimes

 

[quicknss]

having other residencies in the hospital like surgery and anesthesia generally means that when you rotate off-service your educational value is greater.

 

[Powdermonkey]

It does exist in a few places. I interviewed at one way back when and didn't go there.

......

Please. Do tell. This, I think, is what I would enjoy.

 

[deleted65604]

having other residencies in the hospital like surgery and anesthesia generally means that when you rotate off-service your educational value is greater.

Why do you believe this?

 

[quicknss]

Why do you believe this?

If there are other residencies in the hospitals then the faculty are more used to teaching. Academic faculty teach so you will be rotating with teachers not just docs doing their day job.

 

[emoregon]

These threads are always popular. I think one item not mentioned is throughput. It seems most county places have large ED boarding which is a plus for continued ICU care, but I imagine really cuts into how many patients you see. For most of us who will work in the community after residency, our paycheck often depends on how many patients we see. One perk at a more academic hospital (this may not be true everywhere!) is that you have more support staff (less scut work) and better throughput so you are seeing more patients. I'm not saying you should choose a residency so you can get a higher paycheck but remember that baby sitting ICU boarders is not how you will spend the rest of your career. I think managing 6-8-10 fairly undifferentiated patients at once is a true challenge for me to master in my residency. Am I bummed that our ICU admits go up quickly after initial stabilization & diagnosis? Sometimes - especially if they look like they were going to need a tube in a few hours. But am I psyched I get new patients every shift? - absolutely. It's all tradeoffs. Find what works for you. I absolutely second watching out for the above mentioned trauma-philia med students have. Your diagnosis is usually clear, interventions limited (though fun, albeit), and sick ones need surgical care anyway. It's also worth finding out how involved surgeons are in the ED because you can have thoracotomies every shift but if it's all surgeons it won't be helping you out.

My 2 cents

 

[quicknss]

These threads are always popular. I think one item not mentioned is throughput. It seems most county places have large ED boarding which is a plus for continued ICU care, but I imagine really cuts into how many patients you see. For most of us who will work in the community after residency, our paycheck often depends on how many patients we see. One perk at a more academic hospital (this may not be true everywhere!) is that you have more support staff (less scut work) and better throughput so you are seeing more patients. I'm not saying you should choose a residency so you can get a higher paycheck but remember that baby sitting ICU boarders is not how you will spend the rest of your career. I think managing 6-8-10 fairly undifferentiated patients at once is a true challenge for me to master in my residency. Am I bummed that our ICU admits go up quickly after initial stabilization & diagnosis? Sometimes - especially if they look like they were going to need a tube in a few hours. But am I psyched I get new patients every shift? - absolutely. It's all tradeoffs. Find what works for you. I absolutely second watching out for the above mentioned trauma-philia med students have. Your diagnosis is usually clear, interventions limited (though fun, albeit), and sick ones need surgical care anyway. It's also worth finding out how involved surgeons are in the ED because you can have thoracotomies every shift but if it's all surgeons it won't be helping you out.

My 2 cents

Some places that board frequently and for long periods combat the "baby sitting" of boarded patients by having an ED hospitalists take care of admitted patients that must remain in the ED for really really long waits. I've seen this both in NYC and in CA

 

[EMMD2009]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

All procedures would therefore, go to ER residents. Anesthesia rotations would be designed simply to give massive numbers of intubations to ER residents. Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't). Trauma wouldn't be a big stupid gawk-fest with 2 medical students, 2 ER residents, 2 surgery residents, and a gaggle of pharmacists/nursing students, etc., let alone the legitimately needed nurses and techs necessarily involved. All hospital codes would be run by ER residents that come up from the ER. ICU rotations would be an unadulterated procedure-fest. Could it exist? Would you agree? Why, why not?

Christiana meets 1, 2 and 3 at a tertiary care center that sees 120k (not counting our 2nd hospital or peds hospital) per year with plenty of acuity (specifically we see lots of dissections and AAA).
As far as trauma, we often see 15-40 pre-hosiptal trauma activations per day, most of which are blunt (which is more interesting anyway), but 1-2 GSWs or knife attacks per day.

 

[docflanny]

There is NO WAY that I would ever consider Regions in St. Paul, MN to be a "county" hospital. The environment is way to nice there to be considered a "county" type environment.

 

[nawla18]

.

 

[theCamel]

i'm a resident at a 'county' program (LAC+USC) and i think a county program is better defined by its patient population than by its services/on call specialties/resources/etc which can vary widely. keeping in mind that i wouldn't have trained anywhere else, i don't recommend county programs to everyone because it takes a certain fortitude at times to deal with 'county' challenges.

that being said, there are a lot of damn good places out there and you're best served by checking them out for yourself because a lot of what people have posted in this thread (in my opinion) is ummm... not accurate.

 

[deleted65604]

i'm a resident at a 'county' program (LAC+USC) and i think a county program is better defined by its patient population than by its services/on call specialties/resources/etc which can vary widely. keeping in mind that i wouldn't have trained anywhere else, i don't recommend county programs to everyone because it takes a certain fortitude at times to deal with 'county' challenges.

that being said, there are a lot of @#!*% good places out there and you're best served by checking them out for yourself because a lot of what people have posted in this thread (in my opinion) is ummm... not accurate.

What is inaccurate?

 

[Hamhock]

\
You absolutely have to be able to stabilize any patient that is salvageable, but after that the "right" thing to do is going to be hospital dependent. Take DKA for example. At my med school (major county shop), the right thing to do was to continue ordering the alternating q1h VBG and lytes, titrating the insulin drip, repleting lytes, and the patient would usually have their gap cleared and be off the drip before an ICU bed opened up. In residency, the right thing to do was to get the patient stabilized, get a set of repeat labs to make sure the patient still needed the ICU, and then admit. In my first community job, the right thing to do was to identify the patient was in DKA and immediately call the intensivist to work on an ICU bed.

Calling immediately helped me out because it reduced my workload and it helped the patient out because, with a minimum of 4:1 pt-nurse ratio, if I could get q4hr labs done it was a major coup.

Yes, let's take DKA as an example:

I would much rather train at the "county" shop that required the both procedural and cerebral skills to manage the sick DKA ((yes, folks - true DKA (especially pediatric first-timers) is tough)) for the first 24+ hours than the place that either identifies the disease and - dare I say - triages the patient to the MICU or PICU.

The most universally understood reason for this?:

I can much more easily adapt to/learn to work in a place where I just call the appropriate service than I can learn to handle - on my own - for the first time - without a PICU attending upstairs - the 7F no PMHx with HR 150, SBP 80, RR 50, pH 6.8, glu 450, K+ 2.4 (or 7.6), bicarb 6 with imminent need for intubation.

I would rather not be "fast" for my first year of "private" practice than not know how to handle "whatever walks in the door" for the first few hours/deal with a preventable pediatric death.

HH

 

[ORL10]

I train in a " community" hospital that is a level 1 trauma center sees about 100k annually. We have no anesthesia residents and I have been asked on off service rotations to help crna's intubating in the icu in difficult airway algorithms, if I was not originally asked to perform the intubation ( it seems crazy that in the middle of the night anesthesia attendings and or residnts are not at bedside for intubation of icu or floor patients.) We do have surgery residents that despise the er evaluation of trauma and are almost never found during trauma activations if a trauma code goes to the or leaving the Ed resident as the sole physician running the trauma codes ( we do have our er attendings nearby should you need them).

I constantly hear this idea that gsw's and stab wounds are " much easier to handle and less intellectually stimulating" than blunt trauma patients. I could not disagree more. Penetrating Trauma patients provide unique opportunity on difficult airway algorithms that you just don't tend to see in medical or blunt trauma patients. My 3 cric's have all come on penetrating trauma patients, one with a gsw to the neck, one a partial decapitation, and another with hard signs of arterial injury after a stab wound to the carotid with an expanding neck hematoma while the trauma team was in the or doing an exlap on a gsw to the abd. Sure i have done awake intubations in the obese medical patient or in patients with airway masses, but LMAs fiber optic scopes and e newest edition
http://www.epmonthly.com/features/c...novations-could-expand-fiberoptic-use-in-eds/

Has prevented the need for an abundance of cric's on medical patients.

In addition there have been multiple times that penetrating trauma patients with evidence for need for operative intervention cannot go to the or because the trauma attending is in another case, this especially occurs in the summer. Therefore you are stuck temporizing a hemorrhagic shock patient with over a liter coming out of their chest tube initiating mtp, preventing hypothermia, avoid coagulopathy etc... I realize this is not ideal, but it is reality.

These skills in my mind are helpful especially for our residents that stay on the south side of Chicago where there is a lot of violence unfortunately, and work as a community attending and the walk-in gsw or stab wound needs to be managed emergently before transfer.

IMHO

 

[ORL10]

I train in a " community" hospital that is a level 1 trauma center sees about 100k annually. We have no anesthesia residents and I have been asked on off service rotations to help crna's intubating in the icu in difficult airway algorithms, if I was not originally asked to perform the intubation ( it seems crazy that in the middle of the night anesthesia attendings and or residnts are not at bedside for intubation of icu or floor patients.) We do have surgery residents that despise the er evaluation of trauma and are almost never found during trauma activations if a trauma code goes to the or leaving the Ed resident as the sole physician running the trauma codes ( we do have our er attendings nearby should you need them).

I constantly hear this idea that gsw's and stab wounds are " much easier to handle and less intellectually stimulating" than blunt trauma patients. I could not disagree more. Penetrating Trauma patients provide unique opportunity on difficult airway algorithms that you just don't tend to see in medical or blunt trauma patients. My 3 cric's have all come on penetrating trauma patients, one with a gsw to the neck, one a partial decapitation, and another with hard signs of arterial injury after a stab wound to the carotid with an expanding neck hematoma while the trauma team was in the or doing an exlap on a gsw to the abd. Sure i have done awake intubations in the obese medical patient or in patients with airway masses, but LMAs fiber optic scopes and e newest edition
http://www.epmonthly.com/features/c...novations-could-expand-fiberoptic-use-in-eds/

Has prevented the need for an abundance of cric's on medical patients.

In addition there have been multiple times that penetrating trauma patients with evidence for need for operative intervention cannot go to the or because the trauma attending is in another case, this especially occurs in the summer. Therefore you are stuck temporizing a hemorrhagic shock patient with over a liter coming out of their chest tube initiating mtp, preventing hypothermia, avoid coagulopathy etc... I realize this is not ideal, but it is reality.

These skills in my mind are helpful especially for our residents that stay on the south side of Chicago where there is a lot of violence unfortunately, and work as a community attending and the walk-in gsw or stab wound needs to be managed emergently before transfer.

IMHO

 

[Arcan57]

I would rather not be "fast" for my first year of "private" practice than not know how to handle "whatever walks in the door" for the first few hours/deal with a preventable pediatric death.

HH

That's a false dichotomy. The question is does training to manage hour 12 of DKA have benefit to the EP? Yes. But it's not as useful as seeing 3 patients that could have been in that room if it wasn't tied up by the DKA ICU hold. It's possible to see horrible disease without the poor ancillary staff and complete lack of training in customer service that's associated with a county hospital. Outside of county hospitals, satisfying your patients (and by extension your boss) is a core skill without which unemployment soon follows.

Clearly there are county program grads with excellent PG scores, but it's a tough adjustment to go from the county environment to a place where PG and through-put are the chief determiners of success (ie most current EDs).

 

[deleted65604]

That's a false dichotomy.
Clearly there are county program grads with excellent PG scores, but it's a tough adjustment to go from the county environment to a place where PG and through-put are the chief determiners of success (ie most current EDs).

I agree. If you think speed isn't critically important in a good ER physician, you are mistaken. When you are single coverage, and 12 patients check in in 2 hours, you darn well be fast and good, or you and your patients are screwed. In the back of your mind at all times has got to be throughput in the department. Until you are actually out on your own, practicing as an attending in single coverage, this doesn't hit home.

 

[la gringa]

throughput/LOS is something that just wasn't stressed where i trained, save for an attending or 2 who pushed you to move what could move. the rest just sat back for the most part, and let the pace of the place take over...

flash forward to single coverage in a very variable community ED... took a lot of getting used to!!!

but i can take care of any sick patient alone or with just 1 nurse b/c of what i learned in my county residency... and am more attuned to taking care of the uninsured/homeless/etc than many of my colleagues.

haven't had any issue w/ patient satisfaction - but that's my personality and has nothing to do w/ where i trained 😉 born extrovert, mostly enjoy my work, and smile a lot.

 

[theCamel]

I agree that the county label is not a helpful one. If I could create the perfect ER training environment, it would include the 4 following things:

1. A busy place with high acuity.

2. No anesthesia residents.

3. No ortho residents.

4. No general surgery residents.

This would have to be therefore, a level 2 trauma center.

All procedures would therefore, go to ER residents. Anesthesia rotations would be designed simply to give massive numbers of intubations to ER residents. Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't). Trauma wouldn't be a big stupid gawk-fest with 2 medical students, 2 ER residents, 2 surgery residents, and a gaggle of pharmacists/nursing students, etc., let alone the legitimately needed nurses and techs necessarily involved. All hospital codes would be run by ER residents that come up from the ER. ICU rotations would be an unadulterated procedure-fest. Could it exist? Would you agree? Why, why not?

my shop is similar to your described utopia

i've never seen anesthesia once ever during residency, and i'm finishing in june. they're not allowed in the dept. and yeah, we are busy as well. not as crazy as the late 80's drug wars, but still more than busy enough.

we have ortho residents, which is great for the patients. we do all procedures, and will only consult for dispo or for complications (we do our own reductions, etc). they're good to have around to dispo the osteomyelitis pts, the open fx's, the CFI's/FTS', and if you treat them right and pay attn you can actually learn something from them.

same with gen surg. they don't do anything in our ED procedure-wise, but help with dispo. do you really want to have to beg an attending surgeon to arrange for ercp in a sick cholangitis pt, or sell them on not getting a CT on a slam dunk appy? residents help with getting things done, and once in a blue moon you can learn something from them.

but i do agree about the trauma clusters with their med students and 5 residents shouting all over the place. the only procedure they're allowed to do in the ED is a thoracotomy, and that's if they're there in time. BUT, they're damn good at what they do, and i'm glad when they take our patients to the OR - in fact, i tell anyone that asks that they're the ones you want if you taking care of you if you have a severe trauma anywhere in the LA area.

p.s. we answer all hospital airway codes and arrests as pgy3/4's = massive bonus, and definitely is an important and procedure-filled part of our training

 

[EMdoc10]

How much does "county"/zoo-like/stacked-hallways, overflowing WR-setting residency compromise bed-side learning? I would say lots, but would love to hear other opinions. Personally, I'd like to "learn" at work too, and have at least a moment to process what I learned from my last case, instead of mindlessly moving on from one patient to next.

 

[tsbqb]

Orthopedic residents wouldn't be relied on by ER attendings to be scutmonkeys/ reduction accomplishers and ER residents would come out with solid competence in ortho reduction (which I didn't).

How did you make up for this deficiency after residency was over?

 

[Arcan57]

How much does "county"/zoo-like/stacked-hallways, overflowing WR-setting residency compromise bed-side learning? I would say lots, but would love to hear other opinions. Personally, I'd like to "learn" at work too, and have at least a moment to process what I learned from my last case, instead of mindlessly moving on from one patient to next.

I can see the thinking here, but you're assuming that the doc and not nursing/ancillary services is the rate limiting step at county programs. Most county programs have prolonged cycle times through the ED, so even if there is a tent city in the waiting room the actual time you have with each patient will be longer then in efficient community shops. I'd be more concerned about getting bedside teaching in a place that prides itself on a 2 hr LOS or has some sort of rigorously enforced door-to-doc time.

 

[Arcan57]

How did you make up for this deficiency after residency was over?

I also didn't learn a lot besides how to throw on an sugar tong w/foot plate splint on ortho. In the community, I learned reductions through trial and error and that wonderful, wonderful cheat called procedural sedation. A stick of propofol greatly improves almost anyone's ability to line up displaced distal radius fractures or put back in a shoulder/hip.

 

[MSmentor018]

I also didn't learn a lot besides how to throw on an sugar tong w/foot plate splint on ortho. In the community, I learned reductions through trial and error and that wonderful, wonderful cheat called procedural sedation. A stick of propofol greatly improves almost anyone's ability to line up displaced distal radius fractures or put back in a shoulder/hip.

that's the best way to learn.....that's how i did my ortho month except i cheated and got the c arm from the OR. then I'd text the senior the pic.

 

[MSmentor018]

I'd be more concerned about getting bedside teaching in a place that prides itself on a 2 hr LOS or has some sort of rigorously enforced door-to-doc time.

arcan that's a great point and something I am worried about in the future of residency education. we've let press ganey take over and now turned medicine into a hotel industry. we just implemented it last week so i can't say how it's impacted us yet. any thoughts or is it affecting your shop?