Having been a Duke EM resident, after doing prelim IM at a much more brutal, inner-city NYC hospital, I saw it from a little different light.
"4040" is not all rosy as TommyGunn paints it - the pay had to go up to have more people do it last year. If no one signed up, at least once there was a SAR (a 3rd year) that was assigned to do it, without being paid (I can tell you who it is). In addition, there were 3 types of people who did 4040 - the diligent, who did the right thing; the lazy bastards, who did every- and anything they could to do as few admissions as possible; and the Duke über-brainies that would use the most convoluted arguments not to admit (I can tell you two - and the main arguments were "this patient doesn't need to be admitted!" - with the implied, "Are you REALLY that stupid?" - or, "this patient is TOO sick/not appropriate for general internal medicine").
And I like to think I know just a little of what I'm talking about, as I was (I think) the only off-service resident to be named in the SAR graduating dinner in the spoof program (because of my penchant to "call it like I see it", and I would say "hey, I have an interesting (or "such a GREAT") case for you!", in my exuberant manner - but, at the same time, if it was not so scintillating or soft, I would tell them that, too).
As far as punitive time in the ED, nope, didn't happen. Wish it did, but it was hard enough to get the scheduled people to show up on time, or make a dent in the patient load. There were more than half of the IM residents that would make a storied effort, especially those that would work the patient up, then give the pt follow-up in that resident's own clinic, but those in the minority made more of an impression, such as those that would see 4 patients in 12 hours - and ask to leave early. Some of the IM residents really liked being in the ED, but those were the same that had a zeal for whatever rotation they were on (one female resident jumped RIGHT into trauma, and was good at it - but that was typical for her), others hated every second, and then there were the in-betweeners who realized it was a **** sandwich, but knew they had to eat it, so they bit right in.
It's an RRC requirement for primary residencies (surgery, IM, peds, ob/gyn) to do time in the ED, and surgery & ob/gyn can get around it by consulting, but, since IM doesn't have that luxury (since most EM problems are general IM-adult problems, and, as such, if they need to be admitted, they go to IM), working in the ED is part of the deal, like it or not. People that were at Duke before there was an EM program noticed the difference - after EM started, there was nothing left to do - any test that was needed was either done, resulted, and evaluated, or ordered and performed, and not evaluated yet - leaving the admitting teams with little to do except data-mining; patients had their central lines, their bloods drawn, LP's done, paracenteses performed. Dr. McNeill and Dr. Muir asked Dr. Clem, the EM division chief, to leave something for the IM residents to do. As of June 30, there was a PGY-2 (now 3) IM resident that had never done an LP.
There is still a residual sentiment among IM that EM (and EM residents) are substandard (which is manifested and reinforced by med students who've been conditioned to the same), but we learned that it was easier to bend like a reed when the IM resident was being overbearing or unreasonable ("sure, we can order a ceruloplasmin level"), as long as that would get them to see the patient. To have someone do a "punitive" ED shift defeats the educational purpose, and would be more of a hindrance than any help.
