EM PGY 1-4, 1-3, 2-4???

Discussion in 'Emergency Medicine' started by Cody1MD, May 1, 2002.

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  1. Cody1MD

    Cody1MD USF MPH/DrPH 10+ Year Member

    Jan 25, 2002
    FLL, FL
    Can some one explain the difference between these type of residence programs in emergency medicine. I am interested in getting a lot of exposure in truama and critcal care in the emergency department. Does it beneift me to do the 1-4, since its a total of 4 yrs? Are these programs equally competitive when applying for a rsidency? :confused:

    Thanks for the info!
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  3. Mr. happy clown guy

    Mr. happy clown guy Senior Member 7+ Year Member

    Jul 30, 2001
    Are you following me?
    That is the great debate, but you will recieve PLENTY of experience at any RRC accredited EM program of PGY1-3.

    Go to the <a href="http://www.saem.org" target="_blank">www.saem.org</a> website and look for the student information. There are a couple of articles regarding residency length found there. It is a GREAT website for students!!
  4. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
    I think most people (medical students applying to ER nonwithstanding) would agree that its ridiculous that EM is only 3 years. There's just too much to learn. I forsee that as the specialty of ER gets more mature, that they may all become 4 years.
  5. bigfrank

    bigfrank SDN Donor 7+ Year Member

    Feb 20, 2002
    I would respectfully disagree with droliver. Due to the fact that EM deals with a substantially greater amount of primary care than most people realize, I think that 3 years are sufficient. The training will be perfectly adequate.

    This is why the 3-year programs are hands-down the most popular choices among applicants. And to answer the original poster's question, yes, 1-3 programs are more competitive, as a rule.
  6. Mr. happy clown guy

    Mr. happy clown guy Senior Member 7+ Year Member

    Jul 30, 2001
    Are you following me?
    Please read the <a href="http://www.saem.org" target="_blank">www.saem.org</a> articles.

    There are legit points by both parties. The more intense the training early on (off the IM floors and in the ED) the better. Look how the curriculum is set up by each program, that should help.
  7. tonem

    tonem Senior Member 10+ Year Member

    Sep 13, 1999
    I'm with Frank on this one...everyone I've talked to from attendings on down have been unanimous in their belief that three years is enough. I've also been told by people in the EM field that 4 year programs are going to become more and more scarce because the government is only paying for three years of training so the expense of that fourth year will be picked up by the residency program.
  8. BCE

    BCE Junior Member 7+ Year Member

    Jan 4, 2003
    Sorry to dredge up an old thread, but I was fascinated by the 1-3,1-4 debate.

    Ive trained in Australia which is a 5 year EM programme, but I know that Canada offers a 5 year programme as well.

    Ive worked in busy departments for 50-60 hours a week for most of my residency.

    If you believe the published residency survey's from the US my practical and clinical experience exceeds considerably that which is obtained in a 3 year programme - which is what you would expect with an extra 2 years.

    FOr those of you that support a 3 year programme - how can you believe that 3 years is enough training ?

    It dosnt help either with turf wars with other specialities such as trauma - all the debates Ive seen at some point degenerate down to the "EM is only a 3 year residency and trauma is 5 + a fellowship"

    Im sure there are pro's and con's to both ways of doing things and the US system has evolved how it is for good reasons - but in my mind the field of EM is vast and technical skills expected are expanding - how can you fit all of that plus get good experience with all the common presentations in 3 years.

    Just my opinions - interested in others views.


  9. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
    Wow, another voice of reason! :D
  10. Ponyboy

    Ponyboy Senior Member 10+ Year Member

    Jan 27, 1999
    To give a Canadian perspective:
    There are two paths to EM in Canada.
    The first path is a three year course, consisting of two years of family medicine followed by a one year fellowship in EM (usually consisting of rotations in EM, surgical specialities, trauma, etc).
    The second path is a five year program that includes extensive rotations in Internal medicine, surgical subspecialites, trauma, research and a mini-fellowship (about one year) in a subspecialty of EM.
    The common belief is that ten years out of residency, graduates from either program are indistinguishable. However, before that time, five year graduates tend to be more comfortable with trauma and are usually more comfortable working in academics as well.
    It is predicted that eventually five year grads will work in the tertiary-care hospitals (which are usually the trauma centers in Canada) while the three year grads will tend to work in the community hospitals.
  11. jawurheemd

    jawurheemd xx ToXiC xx 10+ Year Member

    Aug 8, 1999
    I do believe that a 3-year emergency medicine residency is enough to give you the clinical experience needed to practice competently in the real world. I do not, however, feel that this time is enough to master other aspects of emergency medicine such as research and administration. Now does a 4-year program give you that experience? I'm not sure that it does -- mainly because the focus isn't there. I would rather do a 3-year residency followed by a fellowship -- whether it be research, administration, informatics, or some clinical subspecialty. Just my feelings.

  12. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    Yes, someone coming out of a four or five year training program is going to be better prepared than someone coming out of a three year training program. But if you compare someone coming out of a four year program with someone who has done a three year program and been an attending for a year, the main difference is that the four year guy is poorer. You had better have an awfully good reason to do that fourth year (location or some rotations that are really important to you). My opinion is do the three, and if you want more do a fellowship. Four year programs will continue to disappear as many of the best applicants begin to migrate away from Olive View, Cincinnatti, and Denver etc and toward Harbor, Pittsburgh, Hennepin etc, simply because they want a three year program. Whether one or the other is better doesn't matter, economics will ensure that there are only 3 year programs before too long.
  13. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
    I disagree. Further training under supervision is the difference. This process makes better doctors & is hard to argue against. Its interesting to see many of the other western countries feel up to 5 years is required for competency. I have a lot of respect for well trained Emergency room physicians, but it strikes me (and many other physicians) that 3 years of training is just not enough proctored training for such a broad field.
  14. Apollyon

    Apollyon Screw the GST Lifetime Donor 10+ Year Member

    Nov 24, 2002
    EM used to be 2 years. Every specialty thinks whatever they have is insufficient.

    However, there's a reason that PGY-4 programs have been called the "$150,000 mistake". Even so, if the one year is a deal-breaker, maybe you might have to re-evaluate the whole idea. In your first few years, if you want to work 20 shifts a month, you can make up the difference. As always, it's what you put into it, which shows what you get out of it.

    One thing to be wary of is 4 year programs that use the PGY-4 year as a "sub-attending" year, without contributing to the education of the resident.
  15. overnight

    overnight Junior Member 7+ Year Member

    Nov 11, 2002
    Why do pro-4 yr program people seem to think one stops learning after residency?
    You can learn just as much as a 1st year attending as you can as a 4th year resident; arguably, more.
    One doesn't stop reading or consulting with more experienced colleagues after residency.
  16. BCE

    BCE Junior Member 7+ Year Member

    Jan 4, 2003
    Im not pro-4yrs, Im pro-5 !

    Of course you dont stop learning after residency - but supervised experience and directed teaching with an exam at the end - I believe makes you more focused than discussing a case with a colleague or looking something up. To take your argument a step further why not shorten the programme to 2 years -
    since working as an attending you learn as much as being a resident. Why is 3 years a magical number - I dont know the perfect length 4 yrs or 5 yrs - but 3 isnt enough IMO

    Why are other programmes longer - because other specialities believe to acquire the knowledge and skills for that speciality they need to be - I think EM is selling itself short by producing attendings from 3 year programmes. Maybe we should start selling the 3 year residency to the other specialities - cause they are just wasting their time doing 4,5,6 years - because all that extra experience and skills you can pick up as an attending - carnt you ?

    I personally dont believe that all the knowledge or skills can be picked up in 3 years - just my opinion - no offense to anyone intended.


  17. docB

    docB Chronically painful Moderator Emeritus Lifetime Donor 10+ Year Member

    Three years was plenty. Four is fine too but only if you can moonlight. In fact moonlighting helps however long your rogram is, both financially and in terms of competency. As for doing surgery style 5 year stints forget it. I think that the reason they have to go so long is to get the time in the OR with their attendings. There are only so many cases per day and any individual resident only gets to scrub on so many (and very few in the first 2 years). So it takes them longer to get the attending supervised time to gain competency in their field. EM gets more direct attending contact than any other specialty. An EM faculty sees every patient and discusses them with the resident and this goes on 24/7.
  18. augmel

    augmel Senior Member 10+ Year Member

    Oct 7, 2002
    so why doesn't anyone argue that 3 years isn't enough for IM? IMHO er doesn't require more knowledge than IM or FP but no one says that those programs are too short. (ok some say fp is) in fact, most the rural er's in this country are still staffed by internists or fp's, and they have to know chronic care as well. yeah, er is broad but that is why we have continuing ed and consults.
  19. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
    The reason I don't think that anyone makes the argument for IM extending to 3+, is that the multiple fellowships in fact do that already
  20. droliver

    droliver Moderator Emeritus 10+ Year Member

    May 1, 2001
  21. m and m

    m and m Member 7+ Year Member

    Nov 7, 2002

    EM has fellowships too, though. And even if you don't do a fellowship, IM docs who don't do a fellowship are not widely regarded as incompetent and/or lacking experience by other specialties. As for surgery and OB/GYN being longer, I think it really comes down to a physical skill that takes time to master (as someone mentioned earlier OR time is not granted). For ED residents, the physical skills we need to master are not an issue in most programs. As for saying that 5 years is better, why not make it 10 years since apparentely things even out by then. I am sure I would be much better trained in a 10 year program and I would be able to tell my surgery collegues to just ........... Well you get the point. I think that after 3 years your learning curve flattens out considerably.

    I think that when the "I trained longer than you" argument is made by other specialties, it is really a petty attempt at getting back at us because we called them in the midle of the night.

    Talking to 3rd year residents who are about to go out on their own, they feel ready.
  22. DrQuinn

    DrQuinn My name is Neo Moderator Emeritus 10+ Year Member

    Dec 6, 2000
    Ugh, the thought of doing a 5 yr EM residency is making my pylorus quiver.
  23. jashanley

    jashanley Senior Member 10+ Year Member

    Dec 9, 2002
    Being an IM/EM I have no say now.......but I think it is whatever makes you feel like you will be comfortable managing the board. If you prefer 4 then do 4, and if you want 3 go for it. It doesn't matter each one can be argued for and against well. Do what you want I say.....I am.
    And please don't call me masochistic or sadistic.......I am well aware of my situation. Thanks
  24. EMRaiden

    EMRaiden Senior Member 10+ Year Member

    Dec 19, 2002
    As a 3rd year getting ready to start in the real world I can say that I don't think I'd every feel completely ready no matter how long I trained. I do feel however that 3 years is enough supervised training to perform well and take care of patients (otherwise all of the 1-3 grads would be failing the boards left and right). Medicine is a process of lifelong learning and eventually you just have to go and do it.

    When I was looking at the possibility of 3 yr vs 4 year programs, I asked myself one question, I said "Self, what more can this program do with me for that extra year". And in many palces the answer is, "Use me as cheap labor to staff the ED". If you want more training get more- do a fellowship (http://www.saem.org/services/fellowsh.htm). Go do forensics at UL or HBO at LSU or Tox in San Diego. Expand your knowledge base.

    A fourth year is, IMHO, an opportunity to see more patients with different presentations of disease for 40K. Getting a job is the opportunity to see more patients with different presentations of disease at 200K.

    My 2 pesos...

    "My cat's breath smells like cat food."
    ---Ralph Wiggums
  25. Ponyboy

    Ponyboy Senior Member 10+ Year Member

    Jan 27, 1999
    Again, taking an example from Canada:
    To be licensed in Internal Medicine, a Canadian doc has to do at least four years of a residency in Internal medicine. The last year can be the first year in a fellowship but to practice general internal medicine, a fourth year is required. The same applies to pediatrics. It's five years for anesthesia (vs. four).
    Does this make a difference? In terms of anecdotal information, several Royal College Examiners have stated that there is almost a 100% failure rate for US trained pediatricians and anesthesiologists when they take the Royal College exams. No information on Internal Medicine. So, is an additional year of subspecialty rotations a waste of time? Maybe. Maybe not.
  26. shaft

    shaft Member 7+ Year Member

    Oct 23, 2002
    Every four year program I visited allowed moonlighting. At one (Cinti) there were a plethora of $100+/hr opportunities in the area. So if you want to work 3-4 extra shifts a month it isn't a necessarily a $40K job for that year. (If money is the argument...)
  27. docB

    docB Chronically painful Moderator Emeritus Lifetime Donor 10+ Year Member

    That's very true. Moonlighting does in fact devalue board certified EPs. It does not provide the optimal level of care. And you can huff and puff 'til you're blue in the face and it won't go away. The fact is that the first question asked at many job interviews is "Do you moonlight?" Medical directors want resident who have gotten their feet wet, know about billing and can move the meat.
    I think that in years to come there will eventually be enough BC EPs to fill all the slots and than moonlighting will die but not until then.
    BTW ACEP et. al. have lots of positions that are based on idealism rather than reality. For example ACEP would like to eliminate holding orders but it's done in a very large number of hospitals.

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