EM residencies that do not consult much?

[Status Sciaticus]

Hello everyone,

Im an MS3 looking at EM as a specialty choice and consequently looking at away rotations and planning ahead for residency.

I wanted to get some advice on how to go about finding out which programs that dont consult much to ortho, IM, etc.. and do their own procedures, reductions, etc..
I figure this would better equip me for my career by learning to do things myself rather than just consulting a specialty for a problem.
I searched the SDN away rotation reviews but I havent found more than a few programs that do this.
Any help is great!

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[Tenk]

If a program has a smaller hospital in their rotation, chances are they won't have Orthopaedic residents coming down and stealing your reductions. At bigger sites and academic places this is more the norm just due to time constraints and also laziness.

 

[SpacemanSpifff]

Unopposed residencies. Corpus Christi comes to mind.

 

[tux4]

From what I heard from a couple other doctors, consulting is just what they do at some places but they don't HAVE to do. It is just the trend so others follow suit. Is this the case or are there some sort of requirements at these institutions that you have to consult people for things that are even within our scope of practice. I get that it saves you the time of dealing with something so you just give it to someone else, but besides that I don't see a reason to abide by this regardless of which residency.


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[gman33]

Look for a place that has few other residency programs.

I trained at a program where we spent half the time at an academic site and half the time at a community site.

It was nice but to learn who to operate in both settings.

 

[fahimaz7]

MMC. Only 60 residents per year in the hospital. No ortho, derm, ophth, ent, etc

 

[Status Sciaticus]

Unopposed residencies. Corpus Christi comes to mind.

From what I heard from a couple other doctors, consulting is just what they do at some places but they don't HAVE to do. It is just the trend so others follow suit. Is this the case or are there some sort of requirements at these institutions that you have to consult people for things that are even within our scope of practice. I get that it saves you the time of dealing with something so you just give it to someone else, but besides that I don't see a reason to abide by this regardless of which residency.


Sent from my iPhone using SDN mobile app

Agreed, but the issue is that the ED here consults out to ortho because thats the protocol and I presume it might be the same elsewhere.

MMC. Only 60 residents per year in the hospital. No ortho, derm, ophth, ent, etc

Thanks.
So far I found :
MMC
UT-Austin
Christus Spohn

Hopefully others can add more as time goes on.

 

[TooMuchResearch]

Agreed, but the issue is that the ED here consults out to ortho because thats the protocol and I presume it might be the same elsewhere.


Thanks.
So far I found :
MMC
UT-Austin
Christus Spohn

Hopefully others can add more as time goes on.

Sometimes I consult Ortho because I know a fracture is unstable, reduction won't hold, and I know our Ortho group will take the patient to the OR today if needed.

Could I manipulate the fracture and then call Ortho when the reduction fails? Sure. But why torture the patient more than needed when I know the outcome is the same either way.

Do I reduce things that I think will hold? Yes, and they follow up in clinic.

 

[alpinism]

As a general rule of thumb EM programs at hospitals with highly regarded medicine/surgery departments (US NEWS top 50 schools) will be more consult heavy.

 

[coachB]

Hello everyone,

Im an MS3 looking at EM as a specialty choice and consequently looking at away rotations and planning ahead for residency.

I wanted to get some advice on how to go about finding out which programs that dont consult much to ortho, IM, etc.. and do their own procedures, reductions, etc..
I figure this would better equip me for my career by learning to do things myself rather than just consulting a specialty for a problem.
I searched the SDN away rotation reviews but I havent found more than a few programs that do this.
Any help is great!

Consults are not necessarily a bad thing if you have consultants that teach and you make the time and effort to learn. Sure, if you just make the consult and don't get involved, you're not going to learn how to do it. But in teaching environments, many consultants are happy to help teach interested learners. Ask to be involved in the procedure, whatever it is.

 

[Apollyon]

Consults are not necessarily a bad thing if you have consultants that teach and you make the time and effort to learn. Sure, if you just make the consult and don't get involved, you're not going to learn how to do it. But in teaching environments, many consultants are happy to help teach interested learners. Ask to be involved in the procedure, whatever it is.

Exactly - consult it out first, and be there, ready and eager. Next time, do it yourself, or tell them "I want to try, but I need you as backup in case I fail". By the third time, when they know you're not a tool, you're good to go, and, if you call, they know it's the real thing, and not just being lazy.

 

[aliraja]

Exactly - consult it out first, and be there, ready and eager. Next time, do it yourself, or tell them "I want to try, but I need you as backup in case I fail". By the third time, when they know you're not a tool, you're good to go, and, if you call, they know it's the real thing, and not just being lazy.

I'll second that - especially as an attending. If you're out in the real world and know your consultants well, they're a lot less likely to whine about your consults if they know that you know your stuff and have given it the (knowledgeable) old college try first.

Also, given that Apollyon taught me everything I know about emergency medicine, I usually just agree to whatever he says.

 

[Arcan57]

I'll second that - especially as an attending. If you're out in the real world and know your consultants well, they're a lot less likely to whine about your consults if they know that you know your stuff and have given it the (knowledgeable) old college try first.

Also, given that Apollyon taught me everything I know about emergency medicine, I usually just agree to whatever he says.

I didn't know you were on here.

Agree that life is easier if you don't have a rep for calling BS consults.

 

[carbonizedeyesockets]

When it comes to ortho, Christiana is definitely a place where EM will do the majority of fracture reductions and dislocations since there are no ortho residents and the attendings have better things to do than come down to the ED (e.g. OR, office, stay at home)

As a student, I got to help reduce a trimalleolar fracture. Ortho was only involved via phone.

 

[Dr Mantis Toboggan]

Hennepin County comes to mind of the places I've seen.

 

[GonnaBeADoc2222]

Unfortunately, at our academic site, consultation is king. We are extremely adept at critical care, ultrasound, non-ortho procedures, high volume environments, and most other issues, however ortho, ophtho, and some obscure urgent care topics are weaknesses. Most ortho procedures, except 99% of shoulder reductions, and maybe a few hip reductions, get turfed to the orthopods. It's a combination of EM attending attitudes and also grumpy ortho attendings who whine when the patient shows up in clinic for follow-up if the reduction/splinting isn't all perfect and beautiful. The ortho residents are afraid of their attendings, and are often reticent to allow an ED resident participate in a reduction...but not always. This makes me nervous for practice next year as an attending. Luckily, it seems most (not all) injuries and be dealt with by recreating the mechanism of injury, pushing/pulling a bunch, then splinting in place with some kind of short-term follow up. I anticipate a fair amount of learning on the go as ortho issues come up next year in my first year being an attending. This is an issue that is not isolated to my program and seems pretty widespread.

Lots of times, by virtue of being at a tertiary referral center, consultation is procedurally mandated. You gotta call the Onc fellow for cancer patients that show up, Cards fellow for patients who have an involved Cardiologist, Trauma for certain criteria, Neurosurgery for this or that, etc, etc. As a general rule, 90% of the time, if you are dealing with a consultant/admitting provider who is a resident or fellow, they have received expert training in how to obstruct/delay/defer good patient care. I believe "not helping the ED" is a log-able procedure, and they need about 100 of them to graduate. It is quite refreshing to deal with someone (often at our community site, and often a PA/NP or even a direct resident-attending conversation) who is actually interested in helping you and the patient and not self-motivated to obstruct patient care.

Overall though, I feel pretty good about being an attending next year in terms of knowledge / skills. I think anyplace you go, you will still have to continue "lifelong learning" once you graduate.

 

[Deuce Doc]

Similar to above, my experience with the big, academic medical center was that consultation is the norm--especially with more risk averse EM faculty. The thing that I would add to your search is to consider the academic places with a significant off-site community experience. We got a month or two per year in the community. I thought that this was just a hoop to jump through when I was applying. It became immediately apparent to all the residents though, that this was a hugely important part of the program. It provided an emphasis on so many things that aren't valued in the same way in the academic center--documentation, flow, procedures, etc. Typical EM procedures (ortho) weren't available at my home institution due to the swarm of specialists, and the standard of care, that we call the left-knee-guy for anything involving the left knee. On the other hand, our community site was a much closer simulation to what my life is like now in non-academics--do it if you can, just don't screw it up. Without that portion of residency, I would never have cardioverted anybody in training and probably would have done 1(!) distal radius. By splitting the time with the academic site, we still got the ridiculous number of airways and lines that you want before you graduate.

 

[brk81144]

I trained in a consult heavy er. First few months after residency had a steep learning curve for ortho procedures but thankfully YouTube and google helped me through it...

 

[EMapplicant2017]

Where were you guys on the interview trail? This was the "realtalk" I was looking for. All I got was sunshine and rainbows...

 

[e30ftw]

OP I would not make this consideration a deciding factor. Also no one is going to be able to give you specific information unless you list the exact programs you're talking about, which may be ill advised.

Get into the best EM residency you can that matches your location/life goals.

Study/work hard and learn as much as you can.

If it's ACGME approved and overall a decent program, you will come out ready for community medicine.

Ortho reductions are relatively easy and honestly, fun as long as the ED isn't blowing up while you're taking time to sedate/reduce.

No one ever died from a less-than-ideal distal radius reduction. You can perfect ortho reductions while attending patients at your community job.

Plenty of people die from missed subtle EKG findings or historical details in chest pain patients glossed over due to time stressors.

Learn about the things that will kill people if they are discharged.

 

[deleted547339]

No one ever died from a less-than-ideal distal radius reduction. You can perfect ortho reductions while attending patients at your community job.

Plenty of people die from missed subtle EKG findings or historical details in chest pain patients glossed over due to time stressors.

Learn about the things that will kill people if they are discharged.

This.

 

[gamerEMdoc]

Community hospitals without subspecialty residencies. Gen Surg won't steal many procedures (I don't exactly take out an appendix). Places with IM, FP, Gen Surg aren't a big deal. But once you have ortho, ENT, neuro, neurosurgery, eye coverage, and every other residency and fellowship under the sun, the number of procedures you do will dwindle.

I remember when I was in med school, at the University hospital, it was not uncommon for neuro or neurosurgery to get consulted to do difficult LPs, optho to take out corneal foreign bodies, surgery to do chest tubes, and ortho doing all fractures. In the community ED I trained at in residency though, this was part of our routine practice in the ED, doing all that yourself. Where I train residents, its the same, these are ED procedures you will be expected to do if you work in the real world. Unless you plan on going out and practice at a huge academic center, this is stuff you need to know how to do. This was the biggest reason I chose to go the community route when choosing a residency. Research didn't interest me, I just wanted exposure to as many procedures I could do. And I don't regret that decision to do a community based residency program one bit.

Large academic centers certainly have advantages, I don't want to make this a University vs Community ED battle. And I'm sure that there are plenty of University based programs that aren't as consult heavy. But I'd imagine, as a generalization, that community hospitals without subspecialty residencies (outside of the basic IM, FP, Surgery) are far less likely to be consult heavy when it comes to procedures.

One of the best things about EM training is that if you want to train in a huge academic center with big research resources and tons of subspecialty resources, you can. And if you want to train in a community ED where you have more responsibility when it comes to subspecialty procedures, you can. You can train in whatever environment is tailored to what you want out of training, and no matter what, you'll go to a place that will adequately train you to be a board certified ED doc when you finish.

 

[GonnaBeADoc2222]

Agree with above. ACGME accredited = good to go. You probably rapidly learned on the interview trail that most places are equivalent. The only procedures we farm out are ortho reductions; we do our own cardioversions, LPs, chest tubes, etc (people mentioned above these getting farmed out too - I kinda think that's lame). Now, in hindsight, I would probably prefer a 3 year community training site, rather than the 4 year mega tertiary referral center that I am at. However, I learned a lot the past 4 years (forget about medicine and procedure stuff - I'm talking about philosophy of life/practice from different attendings that by definition just would have been different if I were elsewhere) and am happy that I was here. The medicine/procedures are the EASIEST part of your job. You will learn these wherever you go. Judgement, efficiency, interpersonal skills....these are often the more difficult skills to finesse. Location is key; go where you wil be happy / spend the least amount of money on cost of living.

 

[Old_Mil]

Hello everyone,

Im an MS3 looking at EM as a specialty choice and consequently looking at away rotations and planning ahead for residency.

I wanted to get some advice on how to go about finding out which programs that dont consult much to ortho, IM, etc.. and do their own procedures, reductions, etc..
I figure this would better equip me for my career by learning to do things myself rather than just consulting a specialty for a problem.
I searched the SDN away rotation reviews but I havent found more than a few programs that do this.
Any help is great!

I know this probably sounds good to you at this stage in your training but consider this:

Most hospitals want their emergency physicians to meet certain metrics. Door to doc time, length of stay, bouncebacks are all measured. What percentage of your procedures you do on your own is not. Every time you take yourself out of circulation to start doing sedations and reductions in real life, your metrics deteriorate and the charts start to pile up.

Finally calling a consult and getting what you need out of often reluctant hospitalists and specialists is an art in and of itself. After you finish residency you aren't going to want to work in a place that makes you do all your own reductions any more than Tom Brady would play for an NFL team that told him to carry the ball all season long because decided to save some cap room and go with a roster devoid of running backs.

 

[Old_Mil]

Agree with above. ACGME accredited = good to go. You probably rapidly learned on the interview trail that most places are equivalent. The only procedures we farm out are ortho reductions; we do our own cardioversions, LPs, chest tubes, etc (people mentioned above these getting farmed out too - I kinda think that's lame).

Cardioversions: I do my own now, didn't in residency. It's a skill you can pick up without any trouble after graduation. Not a see one, do one, teach one type of thing.

LPs and Chest Tubes: You absolutely cannot go to a place that farms these out. Wherever you go when you are done with residency you are either going to be doing these without backup, or teaching them.

 

[WildcatS11]

Cardioversions: I do my own now, didn't in residency. It's a skill you can pick up without any trouble after graduation. Not a see one, do one, teach one type of thing.

LPs and Chest Tubes: You absolutely cannot go to a place that farms these out. Wherever you go when you are done with residency you are either going to be doing these without backup, or teaching them.

Who in the world consults for cardioversions? mildly shameful.

 

[carbonizedeyesockets]

Farming out corneal foreign bodies, cardio versions, chest tubes?

Some programs are serving weak sauce.

This is why leadership matters in a department. If you have a strong chair, program director, etc., they'll minimize this sort of crap.

 

[sum dude]

Might want to go to Community Program. Ostensibly not as "prestigious" as the US News programs, but still great Residents, many of which I've found to be more proficient at procedures and "moving the meat" than the ones from big name programs. Many places now also have hybrid programs where you do go to community ED's and run the shop.

Better yet, find one where you can moonlight, where you will really learn what you need to, and get paid to do it.

 

[gamerEMdoc]

Most hospitals want their emergency physicians to meet certain metrics. Door to doc time, length of stay, bouncebacks are all measured. What percentage of your procedures you do on your own is not. Every time you take yourself out of circulation to start doing sedations and reductions in real life, your metrics deteriorate and the charts start to pile up.

Under that logic, you should call plastic surgery to repair every laceration then because it takes you away from seeing patients for 10 to 15 minutes to suture. It literally takes five minutes to reduce the fracture. Nurse sets up for sedation, you walk in the room give a little bit of ketamine and reduce the fracture or dislocation. The tech puts on the splint. That's it. It ties the nurse up for longer, but not the physician. And it bills for a fortune. There are far more basic procedures that destroy your metrics as a physician than fracture or dislocation reduction. Hell I feel like trying to find a female nurse to help me go get a pelvic exam done takes more time on my end sometimes.

Understand, in community practice in most ED's is expected you able to reduce fractures. Telling an orthopedist at 3 AM that they need to come in to reduce a simple closed Colles' fracture because it will destroy your metrics will not win you any friends on medical staff.

 

[mauricekenter]

Getting to do any and all procedures is one of the reasons I chose to do residency at the Christus Spohn Hospital in Corpus Christi. You need to weight the positives and negatives of many other things, but I can definitely tell you that since the only other residency program was FM, we got more than enough procedures to be competent. I graduated 3 years ago and was more than capable to perform just about any procedure coming out on my own (I also did a lot of moonlighting).

Everyone is different and what is important to you might not be important to everyone else. I really wanted to do everything on my own and not consult anyone and I think it made me a better ER doctor for it.

The only caviat to think about is when there are very few other residencies you might not get the best teaching on your offservice months unless you are driven to learn without a strict outline and are self disciplined.

Also just because you consult someone it doesn't mean you can't learn from them and they won't let you do anything.

My 2 cents.

 

[gamerEMdoc]

Also just because you consult someone it doesn't mean you can't learn from them and they won't let you do anything.

Great point. There's nothing you could learn in residency but you can't learn as an attending. There are tons of procedures and tricks that I've learned to do post residency. Medicine is a constantly changing game and there are always new tricks, new equiptment, etc.