EM Resident AMA

[TexasSurgeon]

Have at it.

I thought I was going to go into surgery (lol username) but I now order CT scans and write short notes. Happy to answer any questions or thoughts on the speciality.

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[deleted388502]

Nice to see you here TexasSurgeon!! (fun fact: me and TexasSurgeon met here on sdn almost seven years ago while studying for the mcat and now he is a physician and i’m about to be one in three months )

1. If you could go back and give yourself any advice as a premed, what would it be?
2. What advice do you have for premeds who are stressed about the mcat?
3. What do you wish you had known before going to medical school?

 

[Cognovi]

When you order CT scans, do you bother to type a free text history or question?
When do you finish writing notes and how long does it take?
What is the typical volume of patients you see in a shift?
What is the largest source of burnout in EM? According to Medscape survey, it is either 1) bureaucratic tasks, 2) lack of respect from other professionals, or 3) lack of respect from patients.

 

[Chillbo Baggins]

Have at it.

I thought I was going to go into surgery (lol username) but I now order CT scans and write short notes. Happy to answer any questions or thoughts on the speciality.

Do you refer to the CT scanner as the donut of truth?

Do you think you get decent orthopedic experience at your program?

 

[gyngyn]

I have to discuss workforce projections with my students.
How do you explain them?

 

[SpinDrift]

Do you refer to the CT scanner as the donut of truth?

Do you think you get decent orthopedic experience at your program?

Your avatar is a d-bag

 

[SpinDrift]

You're EM and have a thing for NASA, have you ever heard of Jonny Kim?

 

[Throwaway5129]

What are your thoughts on the job outlook for EM in the future?

 

[TexasSurgeon]

Nice to see you here TexasSurgeon!! (fun fact: me and TexasSurgeon met here on sdn almost seven years ago while studying for the mcat and now he is a physician and i’m about to be one in three months )

1. If you could go back and give yourself any advice as a premed, what would it be?
2. What advice do you have for premeds who are stressed about the mcat?
3. What do you wish you had known before going to medical school?

Hi haha Avenlea and I go way back and I'm honestly a better person because of her. Thanks for being there for me when I needed it.

1) I'd tell myself that a C in organic chemistry or having to take the MCAT multiple times sucks, but that the anxiety and fear of not getting in should not consume you. Failures are to be embraced and every setback is an opportunity for self improvement and that all things worth having in life are very difficult to obtain.

2) I took it 5 times and of those 5, voided once. It's a hard test and I'm not good at standardized exams. Never have been. Premeds: Please don't place your sense of worth on one test. It was very bad for my mental health and I have to actively resist this for exams even to this day.

3) I wish I had known that it's important to prioritize your mental health and needs over relationships. I had a few relationships that really affected my mental health and sense of self worth and had I just put my foot down firmly and told my partners that I could not be with them because of XYZ things, I would have been happier and less stressed out. Avenlea is well aware of this part of my life haha

 

[TexasSurgeon]

When you order CT scans, do you bother to type a free text history or question?
When do you finish writing notes and how long does it take?
What is the typical volume of patients you see in a shift?
What is the largest source of burnout in EM? According to Medscape survey, it is either 1) bureaucratic tasks, 2) lack of respect from other professionals, or 3) lack of respect from patients.

If we are ordering scans on trauma patients, the only thing I write in free text is "trauma" because I don't have time to write things because placing orders is not important compared to addressing the patient and helping out in the trauma bay itself.

I finish all my notes as I finish my shift. It's hard at first when I began residency but I often pick up 2-3 patients at a time and work them up, and give myself about 30 mins in between the shift at times to just write things out as I need to in the notes and it helps me keep my pace because once I complete those orders/consults, and notes, I can try to pick up more. Now, I'm working at writing the note for the patients in under 5 minutes and being more thorough on chart checking and adding history that I find that is still relevant to the patient.

As a PGY-1, I'll see approximately 5-7 patients on a shift that lasts 8 hours and about 8 patients on a 12 hour shift. I'm at a very large level 1 trauma center that sees everything from GSWs/stabbings/MVCs to psych issues and vaginal bleeders. We also see our fair share of primary care medicine because we function as a social safety net hospital for people who would not be able to get care anywhere else. Lots of social issues as well.

I think the largest source of burnout in EM is that in this speciality you have to be able to switch off your emotional sensor and then switch it back on when you leave. And it's very hard to do this. Patients can decompensate any second and you also have to be ready to see anything come into the ED. so it's a lot of emotions you can't act on and when you leave, those emotions don't just disappear. I find myself a lot more burned out, unhappy, and fatigued after several days in the ED or honestly, several days of just nothing but work in the hospital. Does that sort of make sense? I can honestly say that Medscape's 2 and 3 aren't a huge issue. and 1) is something you see in every speciality

 

[TexasSurgeon]

Do you refer to the CT scanner as the donut of truth?

Do you think you get decent orthopedic experience at your program?

I do call it the Donut of Truth and we are very unhappy when the donut is not warmed up and ready to go when patients need it lolol.

I'm actually on ortho right now. I would say that the rotation is what you make of it. We see a lot of ortho at our program, but residency is what you make of it and so you need to try to be proactive on every off-service rotation you do. There's plenty of opportunities if you seek it out. But no, ortho reductions and splints are not handed to you unless you push for them yourself.

 

[TexasSurgeon]

I have to discuss workforce projections with my students.
How do you explain them?

Hey gyngyn, long time! Hope you're well.

It's going to be a problem. I think the 20% drop in EM applicants this year will do something to correct this over the years, however there will always be a need for ER doctors, it's just that they might not be in the locations that were previously desirable. I would tell your students that if there's truly nothing else that makes them excited, to go ahead and go into it but to be aware that in residency it'll be important to network and stay proactive to try to get to know different programs in the area and to make the most out of conferences. To be honest, most of us are a lot more pissed off at NPs and PAs who practice outside their scope and cause complications for patients. I'm fortunate to be at a strong program where there hasn't been an issue with finding jobs for previous classes and I will likely be okay for one as well.

I think EMRA has also taken some measures to mitigate this by working on changing residency requirements and trying to stop the rapid expansion of new programs especially predatory CMGs. Looking at you HCA and Team Health

 

[TexasSurgeon]

You're EM and have a thing for NASA, have you ever heard of Jonny Kim?

Haha he is my idol. I'm a huge fan of him and you should listen to Jocko's podcast titled "The Unimaginable Path of Jonny Kim"

 

[TexasSurgeon]

What are your thoughts on the job outlook for EM in the future?

I think we're going to have 2 separate healthcare systems: one led by idiot NPs and PAs who think they know it all and want independent practice rights. This is where the poor people will end up because it's "cheaper." You'll still have the other side led by physicians. I think for us, there's going to be a challenge of figuring out places to work and we might end up in less desirable locations however there will always be a job for us ER doctors and I'm feeling that the outlook will improve soon too. It's already improving compared to 2 years ago

 

[Chelsea FC]

I thought I was going to go into surgery (lol username) but I now order CT scans and write short notes. Happy to answer any questions or thoughts on the speciality.

Nice to see you here TexasSurgeon!! (fun fact: me and TexasSurgeon met here on sdn almost seven years ago while studying for the mcat and now he is a physician and i’m about to be one in three months )

1. If you could go back and give yourself any advice as a premed, what would it be?
2. What advice do you have for premeds who are stressed about the mcat?
3. What do you wish you had known before going to medical school?

Same lol. Glad y’all doing well!

 

[MateoGM416]

I read the thread title as 'EM resident Against Medical Advice', I think I spend too much time on here

 

[CyrilFiggis]

Other EM resident here:

When you order CT scans, do you bother to type a free text history or question?
When do you finish writing notes and how long does it take?
What is the typical volume of patients you see in a shift?
What is the largest source of burnout in EM? According to Medscape survey, it is either 1) bureaucratic tasks, 2) lack of respect from other professionals, or 3) lack of respect from patients.

- I type the patient’s complaint (LLQ pain, etc) and free text any pertinent hx (recent partial colectomy, hx kidney stones).
- notes depend on their ESI and billing level. I straight forward shoulder reduction has a basic story, ROS, Exam and MDM is 1-2 lines plus a procedure note. For most of the common complaints I have Epic macros I’ve built that reduces most of the work. Our system requires notes for dced patients to be done within 24 hours, 48 for admissions. But our incomplete notes are visible to all so I typically have the HPI done for all patients before my shift ends.
- our interns by October should be seeing at least 1 per hour on a 9-10 hour shift. PGY2-3 are 2+ per hour. But on overnights you’re solo coverage so you may see 20-30+ patients in a 9 hour shift.
- mainly the lack of institutional support both from the administration and other services.

I have to discuss workforce projections with my students.
How do you explain them?

Over saturation of the market by for-profit new residency programs. This is all a cash grab by these for profits to get CMS money. I interviewed at one due to location by family and they had terrible job placement for grads outside of their system. A system that pays poorly and is entirely incentive based which only drives burnout. If you choose EM go to an established residency.

 

[VenusinFurs]

I read the thread title as 'EM resident Against Medical Advice', I think I spend too much time on here

Honestly I wouldn’t advise most of my patients to go into any residency let alone em but that’s a while separate issue :v

 

[Darrow O'Lykos]

Have at it.

I thought I was going to go into surgery (lol username) but I now order CT scans and write short notes. Happy to answer any questions or thoughts on the speciality.

What ended up guiding you towards EM instead of your initial interest in surgery?

Texas MS1 here probably trying to go the surgical route, but I initially had interests in EM prior to starting med school (ACEP's report last summer ensured I started school with my sights elsewhere).

 

[ChiDr]

If you could go back in time, 3rd year/4th year, would you choose the same specialty today?

 

[Chillbo Baggins]

I'm actually on ortho right now. I would say that the rotation is what you make of it. We see a lot of ortho at our program, but residency is what you make of it and so you need to try to be proactive on every off-service rotation you do. There's plenty of opportunities if you seek it out. But no, ortho reductions and splints are not handed to you unless you push for them yourself.

I've gone back and forth on this issue in the past. As a younger resident (or these days if there's a young ortho resident around who hasn't gotten a ton of experience yet), I would obviously handle all reductions and procedural stuff. However, at this point there's really no educational benefit for me to reduce another ankle or wrist (tho they are enjoyable) so I wonder if I should get the ED residents more involved in doing those so they can become proficient for their future practice.

The issue becomes it's way easier/faster for me to just knock it out rather than teaching the EM resident. Also, it is very rare that the EM residents are actively looking to get involved in those situtations; there are some that are about to graduate and go practice in a rural area where they know they're gonna need to be able to do it, but most seem to consult us and just sit in the central hub, working on their note and waiting for our dispo.

 

[TexasSurgeon]

Other EM resident here:

- I type the patient’s complaint (LLQ pain, etc) and free text any pertinent hx (recent partial colectomy, hx kidney stones).
- notes depend on their ESI and billing level. I straight forward shoulder reduction has a basic story, ROS, Exam and MDM is 1-2 lines plus a procedure note. For most of the common complaints I have Epic macros I’ve built that reduces most of the work. Our system requires notes for dced patients to be done within 24 hours, 48 for admissions. But our incomplete notes are visible to all so I typically have the HPI done for all patients before my shift ends.
- our interns by October should be seeing at least 1 per hour on a 9-10 hour shift. PGY2-3 are 2+ per hour. But on overnights you’re solo coverage so you may see 20-30+ patients in a 9 hour shift.
- mainly the lack of institutional support both from the administration and other services.



Over saturation of the market by for-profit new residency programs. This is all a cash grab by these for profits to get CMS money. I interviewed at one due to location by family and they had terrible job placement for grads outside of their system. A system that pays poorly and is entirely incentive based which only drives burnout. If you choose EM go to an established residency.

1 patient per hour by October for an intern is insane. We aim for that by the end of intern year.

 

[TexasSurgeon]

Honestly I wouldn’t advise most of my patients to go into any residency let alone em but that’s a while separate issue :v

It's always like the grass is greener on the other side.

 

[TexasSurgeon]

What ended up guiding you towards EM instead of your initial interest in surgery?

Texas MS1 here probably trying to go the surgical route, but I initially had interests in EM prior to starting med school (ACEP's report last summer ensured I started school with my sights elsewhere).

Honestly, if I had better control over my time management skills, I'd have done surgery. But because EM compartmentalizes your work and you don't take any of it home with you, there was a huge appeal in the speciality to me because I also enjoyed how hands on it was and the diversity of patients that I would see in the ED. I also turned out to like knowing a lot about different things versus going 1 mile deep in one specific area. I also liked how utilitarian EM is as a speciality. Everyone wants an ER doc when **** goes down. So in that sense, I found it to be pretty lined up with my personality

 

[TexasSurgeon]

If you could go back in time, 3rd year/4th year, would you choose the same specialty today?

Yeah I think so. The jobs market is something of a question in the future but I really don't think I could see myself doing anything else.

 

[TexasSurgeon]

I've gone back and forth on this issue in the past. As a younger resident (or these days if there's a young ortho resident around who hasn't gotten a ton of experience yet), I would obviously handle all reductions and procedural stuff. However, at this point there's really no educational benefit for me to reduce another ankle or wrist (tho they are enjoyable) so I wonder if I should get the ED residents more involved in doing those so they can become proficient for their future practice.

The issue becomes it's way easier/faster for me to just knock it out rather than teaching the EM resident. Also, it is very rare that the EM residents are actively looking to get involved in those situtations; there are some that are about to graduate and go practice in a rural area where they know they're gonna need to be able to do it, but most seem to consult us and just sit in the central hub, working on their note and waiting for our dispo.

If you were my attending on a shift and there was a reduction or splint to do, I would absolutely want to be involved in it and learn how you do it and basically mimic it. My favorite attendings are the ones who assume that I will work in the community and as a result make me learn how to do it all on my own. Yeah it takes more time and makes things slower but I'll really remember that shift in the future and it's helpful for my learning.