ER Experiences going into 4th year; and EM/IM interest

[boolin_1]

I am a 3rd year DO student, trying to stay on top of my stuff now come next year when the application craziness kicks into high gear again. Reading about people waiting for their email notification to go off is giving me flashbacks to when I was applying to schools.


My core rotation site is in a small community hospital. Anything moderately complicated gets referred out to a bigger hospital about an hour away. I have this feeling that I'm going to apply ER, so I have been trying to spend extra days in the small community ER to learn some of the ropes. My ACTUAL ER rotation isn't until block 1 / 2 of 4th year. So for me to really get a SLOE to start my application, I need to do one of my 3 third-year electives in ER.

This is where I feel kind of uneasy. I am reading about other peoples experiences during their ER electives and see how much they're responsible for doing. Chasing down labs. Following up on consults. Procedures at the bedside.
Coming from my podunk ass little hospital, I haven't seen any of that stuff. I have barely seen any bedside procedure and I really try to be as proactive as possible to be at the forefront. Basically, I am worried that the glaring differences of rotations sites will show when I am trying to perform well for a SLOE. And that i'll be at an inherent disadvantage.
How does someone try to overcome this?


I am also incredibly interested in a ER/IM combined residency, and I have no idea where to even start with that. Which letters do they want? ER or IM? Do I need a ER/IM letter to really have a shot?

If I only have 3 electives my 3rd year, should I do 2 ER and 1 IM? Not really sure how I should break this down.

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[TTPpentad]

I'm a 4th year student applying EM. I can't say much to the EM/IM residency questions, but as for general EM rotations...your best bet at doing well is being adaptive, proactive and a hard worker who gets along with everyone. I did a 3rd year EM rotation at a non-residency site and it was good for getting my feet wet, especially with learning to present concisely and follow up on patients. For my 4th year audition rotations to get SLOEs, it was the same, just with slightly higher expectations.

All three of my audition sites were extremely different so it's important that you are ready to jump in and adapt quickly to your new surroundings. You learn as you go with each rotation (as with any med school rotation), but always be eager to help (but not annoyingly eager) and really "own" your patients. Follow up on labs, check in with your patient to see if that med worked, ask to help with/observe procedures, call consultants, etc. They 100% do not expect you to know it all, (even as a 4th year auditioning student, the knowledge base expectations aren't that high), but they do expect you to be a positive, team player who is willing to work hard (and not be a d*ck).

Feel free to PM me. I know it seems scary, but you will be fine!

 

[boolin_1]

I'm a 4th year student applying EM. I can't say much to the EM/IM residency questions, but as for general EM rotations...your best bet at doing well is being adaptive, proactive and a hard worker who gets along with everyone. I did a 3rd year EM rotation at a non-residency site and it was good for getting my feet wet, especially with learning to present concisely and follow up on patients. For my 4th year audition rotations to get SLOEs, it was the same, just with slightly higher expectations.

All three of my audition sites were extremely different so it's important that you are ready to jump in and adapt quickly to your new surroundings. You learn as you go with each rotation (as with any med school rotation), but always be eager to help (but not annoyingly eager) and really "own" your patients. Follow up on labs, check in with your patient to see if that med worked, ask to help with/observe procedures, call consultants, etc. They 100% do not expect you to know it all, (even as a 4th year auditioning student, the knowledge base expectations aren't that high), but they do expect you to be a posi

thanks for the response my guy. I appreciate the input. it seems to be more about who is willing to work hard and learn, as well s care for their patients. I was worried that I would be at a disadvantage by not seeing any bedside procedures, but it seems like everyone is deficient to some degree. and that's it's more important to learn on the fly and get the basics down really well

 

[mancub]

Lots of people don't have any ER experience going into 4th year sub-i's, it's more about learning fast and being willing to work hard. If you can get a 3rd-year elective at an ER residency I don't know if you want a SLOE, instead use it to prepare for your aways. You'll get your SLOE's from the 2-3 sub-i's you do not from your third-year elective. Preparing for VSAS and looking into scheduling aways is probably the most important part of the game for you at this stage.

 

[boolin_1]

Lots of people don't have any ER experience going into 4th year sub-i's, it's more about learning fast and being willing to work hard. If you can get a 3rd-year elective at an ER residency I don't know if you want a SLOE, instead use it to prepare for your aways. You'll get your SLOE's from the 2-3 sub-i's you do not from your third-year elective. Preparing for VSAS and looking into scheduling aways is probably the most important part of the game for you at this stage.

so my 3rd year electives are probably going to be at the very end, around mid-May to early August. How would I be able to to get the SLOE needed start the rotation? Because don't I need at least one SLOE starting when I submit ERAS sept 15th? I think my auditions start August 2nd

 

[Tenk]

Some of my favorite students had never done most procedures before I showed them how. Some of my least favorite students had done them many times. It’s more about your attitude, personality and willingness to help and learn that set you apart, not if you’ve sutured, intubated, or central lined someone before.

 

[gro2001]

I am a 3rd year DO student, trying to stay on top of my stuff now come next year when the application craziness kicks into high gear again. Reading about people waiting for their email notification to go off is giving me flashbacks to when I was applying to schools.


My core rotation site is in a small community hospital. Anything moderately complicated gets referred out to a bigger hospital about an hour away. I have this feeling that I'm going to apply ER, so I have been trying to spend extra days in the small community ER to learn some of the ropes. My ACTUAL ER rotation isn't until block 1 / 2 of 4th year. So for me to really get a SLOE to start my application, I need to do one of my 3 third-year electives in ER.

This is where I feel kind of uneasy. I am reading about other peoples experiences during their ER electives and see how much they're responsible for doing. Chasing down labs. Following up on consults. Procedures at the bedside.
Coming from my podunk ass little hospital, I haven't seen any of that stuff. I have barely seen any bedside procedure and I really try to be as proactive as possible to be at the forefront. Basically, I am worried that the glaring differences of rotations sites will show when I am trying to perform well for a SLOE. And that i'll be at an inherent disadvantage.
How does someone try to overcome this?


I am also incredibly interested in a ER/IM combined residency, and I have no idea where to even start with that. Which letters do they want? ER or IM? Do I need a ER/IM letter to really have a shot?

If I only have 3 electives my 3rd year, should I do 2 ER and 1 IM? Not really sure how I should break this down.

I've posted something about expectations of procedural competency for Sub-Is before... here are my thoughts:

1) Procedures I commonly let students do. While I wouldn't expect a sub-I to know all the nuances or necessarily be completely profficient in these by the time the sub-I begins, I would expect them to have a significant amount of familiarity with them so that my teaching/supervision can focus on the finer points. If the student has never done one by the time they start their sub-I, I would be very surprised. If they were very bad at these (ie: required explanation of basic technique/concept, unable to satisfactorily perform the procedure in a straightforward situation, etc) I would be a little disappointed.

• Basic laceration repair
• Abscess incision and drainage
• Peripheral IV placement
• ABG collection and analysis

2) Procedures I sometimes let students do. These would be procedures that students may have had a chance to perform or at least observe before, but not necessarily. I would not expect a student to necessarily be familiar with the technique, but I would expect the student to have read up on the concept and be able to explain the technique, indications, and complications in broad strokes. In the right setting (appropriate patient, department isn't going to hell, student is making a good impression otherwise) I would let a student perform this procedure under close supervision. I would expect most of the teaching to focus on the bread and butter of the technique. If the student had the bread and butter technique down already and this allowed me to offer some advanced tips, I would be impressed.

• Lumbar puncture
• Joint dislocation reduction
• Paracentesis
• Arterial line placement
• IO placement
• Splinting

3) Procedures I rarely let students do. The stars would have to align just right for these. It would have to be the combination of a rock star student, well suited patient, my availability, generous junior residents who would not give me the evil eye for giving these to a med student, lack of nursing supervisors (ie: night shift). If the student knew the technique, indications, contraindications, and complications, I might let them try. If they did not, I would not judge them for it, but probably not let them try.

• Endotracheal intubation
• Central line placement
• Chest tube placement

4) Procedures I would not let any student perform under any circumstances. My expectation would be for students starting a sub-I to know that these procedures happen and why, but that's about it.

• Resuscitative thoracotomy
• Cricothyroidotomy
• Lateral canthotomy
• Transvenous pacing
• Any of the group 3 procedures on children

In general, I would require a student to have at least some grasp of technique, indications, contraindications, and complications of a procedure, and ideally have observed at least one before I let them perform one. Based on that, and the categories I outlined above, I would recommend familiarizing yourself with those aspects, starting with category 1, then working your way down to categories 2 and 3.

By the end of a sub-I my expectation would be that they would be able to describe the basic technique, indications, contraindications, and complications for all of these procedures.

By the time you start your aways, try to be fairly solid with the category 1 procedures at least. Hopefully your surgery clerkship will teach you suturing and abscess incision and drainage. During your medicine clerkship (or ICU month or anesthesia rotation if you have one) try to practice IV placement and ABG collection. Supplement all of those skills with task trainers. Perhaps your school has a clinical skills center you can use?

For category 2 and 3 familiarity through reading and watching procedure videos might be sufficient.

 

[Keladry]

EM/IM programs generally want 2 SLOEs + 1 IM letter. A bunch also want an IM chair letter (which is a form letter the IM department writes for anyone going into IM), so that can be your 4th letter. Happy to chat more via PM.

 

[cyanide12345678]

At most I expect some basic familiarity of suturing and I&D from a med student, other than that, I really have bare minimal expectations from a med student.

It is really a lot about attitude, willingness to learn, eagerness to see patients. And then hopefully at some point, an understanding of the most dangerous differentials that an ER doc has to consider.

If a med student knows the basic chest pain or belly pain work up, then that's a plus.

 

[boolin_1]

Some of my favorite students had never done most procedures before I showed them how. Some of my least favorite students had done them many times. It’s more about your attitude, personality and willingness to help and learn that set you apart, not if you’ve sutured, intubated, or central lined someone before.

thanks. I appreciate the little insight.

 

[boolin_1]

I've posted something about expectations of procedural competency for Sub-Is before... here are my thoughts:




By the time you start your aways, try to be fairly solid with the category 1 procedures at least. Hopefully your surgery clerkship will teach you suturing and abscess incision and drainage. During your medicine clerkship (or ICU month or anesthesia rotation if you have one) try to practice IV placement and ABG collection. Supplement all of those skills with task trainers. Perhaps your school has a clinical skills center you can use?

For category 2 and 3 familiarity through reading and watching procedure videos might be sufficient.

solid advice. thanks for the response!

 

[boolin_1]

EM/IM programs generally want 2 SLOEs + 1 IM letter. A bunch also want an IM chair letter (which is a form letter the IM department writes for anyone going into IM), so that can be your 4th letter. Happy to chat more via PM.

I am definitely going to PM you because there's not of info for me to sift through for EM/IM. do you know if the IM chair letter has to be from someone who has residents under them? (like in EM)
my little hospital doesn't have any residents. and I don't want to assign a letter that ultimately will get tossed.

 

[takeurmeds02]

so my 3rd year electives are probably going to be at the very end, around mid-May to early August. How would I be able to to get the SLOE needed start the rotation? Because don't I need at least one SLOE starting when I submit ERAS sept 15th? I think my auditions start August 2nd

I'm confused by your question. What's your 3rd year schedule? Most schools are starting 4th year in June at which point, your first rotation that will grant you a 4th year SLOE should be done then. Based on this schedule, you can get at least 2 SLOEs in by Sept. 15th. If you happen to start sooner than June, then you may be able to have 3 SLOEs in by Sept. 15th.

 

[Keladry]

I am definitely going to PM you because there's not of info for me to sift through for EM/IM. do you know if the IM chair letter has to be from someone who has residents under them? (like in EM)
my little hospital doesn't have any residents. and I don't want to assign a letter that ultimately will get tossed.

Yeah def feel free, happy to chat.
The letter is supposed to be from the chair of the IM department - I assume your hospital has one regardless of if there are residents. Pretty sure it's a fairly standard level saying where you stand in relation to other students applying IM, although less standardized & less personalized than a SLOE. Most categorical IM programs require them, so I'd ask someone applying just IM if they have one and how they got it. My school sent out an email saying "if you're applying IM sign up for a meeting with the chair" and we chatted for like 5 minutes and he asked my board scores and that was it. That letter def never got mentioned at any of my EM/IM interviews, but many if not most of the EM/IM programs do have it listed on their websites as an application requirement (or did 2 years ago when I applied, at least).

 

[sylvanthus]

Id only apply EM/IM if you have a good reason for it. Youll be kicking yourself come year 5 when your previous interns are now your attendings, if you do no have a solid reason for doing it.

 

[boolin_1]

Id only apply EM/IM if you have a good reason for it. Youll be kicking yourself come year 5 when your previous interns are now your attendings, if you do no have a solid reason for doing it.

i've been internally battling whether I want to actually do it or not. I am fascinated by emergency medicine and I love the pace and the chaos. But I also want to learn about chronic conditions that lead them there, and how better management can prevent them from being there in the first place. its less about me being undecided, and more about the fact that I have an opportunity to learn about management to keep them from getting to the ER in the first place. and I would be less likely to admit them etc

 

[boolin_1]

I'm confused by your question. What's your 3rd year schedule? Most schools are starting 4th year in June at which point, your first rotation that will grant you a 4th year SLOE should be done then. Based on this schedule, you can get at least 2 SLOEs in by Sept. 15th. If you happen to start sooner than June, then you may be able to have 3 SLOEs in by Sept. 15th.

maybe my thinking of the situation is off. so here is my schedule for the rest of 3rd year.
from May 4th (be with you) to Aug 2nd, I have 3 spots open for electives. 1 of those electives has to be at a site with residents on site.

4th year starts Aug 4th and I have 2 CORE's left: EM (at small hospital) and IM that can be scheduled whenever that fall.

So my understanding was that I should have 1 or 2 SLOE's by sept 15th, but by then, I would have only one 4th year rotation finished. so to make sure I have them, I'll have to use some of my 3rd year elective time for ER electives to get my SLOEs. the designation between 3rd and 4th year at that point is really only 1/2 weeks. and as my audition rotations start up, I would gather more letters.

does that make sense?

 

[sylvanthus]

i've been internally battling whether I want to actually do it or not. I am fascinated by emergency medicine and I love the pace and the chaos. But I also want to learn about chronic conditions that lead them there, and how better management can prevent them from being there in the first place. its less about me being undecided, and more about the fact that I have an opportunity to learn about management to keep them from getting to the ER in the first place. and I would be less likely to admit them etc

Dude youll have zero control over keeping patients from coming to the ED no matter how much knowledge you gain. People are dumb, non compliant, other pcp will send them in cuz their office is closing at 5, or "things can get done faster in the ED'. You will have absolutely zero control over who comes to the ED. Also, your knowledge base will not prevent admissions. You cant fix everything in the short time they are in the ED and will not be prescribing chronic medications from the ED as you will not be following them.

I don't think your reasoning justifies an additional 2 years of training and loss of >400k income. You also will very unlikely to be working clinic or hospialist shifts as youll see the pay per hour is horrible in comparison and youll value your freetime by then, trust me.

So, if all you want is to learn more about chronic conditions, buy MKSAP and read on your own time, save yourself 2 years, a **** ton of money and just go EM.

If you want to do critical care, or teach IM and EM residents, those are some of the only reasons I can see doing EM/IM or EM/IM/CC, trust me dude, I just finished an EM/IM/CC program.

 

[takeurmeds02]

maybe my thinking of the situation is off. so here is my schedule for the rest of 3rd year.
from May 4th (be with you) to Aug 2nd, I have 3 spots open for electives. 1 of those electives has to be at a site with residents on site.

4th year starts Aug 4th and I have 2 CORE's left: EM (at small hospital) and IM that can be scheduled whenever that fall.

So my understanding was that I should have 1 or 2 SLOE's by sept 15th, but by then, I would have only one 4th year rotation finished. so to make sure I have them, I'll have to use some of my 3rd year elective time for ER electives to get my SLOEs. the designation between 3rd and 4th year at that point is really only 1/2 weeks. and as my audition rotations start up, I would gather more letters.

does that make sense?

Oh okay, I see. Well a couple follow up questions - can you take your Core EM in slot as your earliest open elective and just push the elective back? Does your school require that you take EM at your home institution first before you can do aways?

How are current 4th years managing to apply? Them and your EM advisor are going to be your your best source of info.

 

[MechEDoc]

i've been internally battling whether I want to actually do it or not. I am fascinated by emergency medicine and I love the pace and the chaos. But I also want to learn about chronic conditions that lead them there, and how better management can prevent them from being there in the first place. its less about me being undecided, and more about the fact that I have an opportunity to learn about management to keep them from getting to the ER in the first place. and I would be less likely to admit them etc

Most chronic problems that wind up in the ER you won't be able to fix.

People make terrible lifestyle decisions (smoking, lack of exercise, obesity, treatment noncompliance) combined with poorly treated sub-clinical mental illness (depression, anxiety, personality disorders) and they wind up in the ER on an ongoing basis. I would estimate that two thirds my patients have a mental health component in the vast majority of my income is derived from poor lifestyle choices rather than acute manifestations of exotic diseases.

 

[boolin_1]

Dude youll have zero control over keeping patients from coming to the ED no matter how much knowledge you gain. People are dumb, non compliant, other pcp will send them in cuz their office is closing at 5, or "things can get done faster in the ED'. You will have absolutely zero control over who comes to the ED. Also, your knowledge base will not prevent admissions. You cant fix everything in the short time they are in the ED and will not be prescribing chronic medications from the ED as you will not be following them.

I don't think your reasoning justifies an additional 2 years of training and loss of >400k income. You also will very unlikely to be working clinic or hospialist shifts as youll see the pay per hour is horrible in comparison and youll value your freetime by then, trust me.

So, if all you want is to learn more about chronic conditions, buy MKSAP and read on your own time, save yourself 2 years, a **** ton of money and just go EM.

If you want to do critical care, or teach IM and EM residents, those are some of the only reasons I can see doing EM/IM or EM/IM/CC, trust me dude, I just finished an EM/IM/CC program.

I appreciate the advice. I realize that a lot of me wanting to go ER/IM might be attributed to me being a eager and bright eyed MS3 lol. I would also like to transition into physician leadership, but that would be after at least 12-15 years of practicing.

 

[boolin_1]

Oh okay, I see. Well a couple follow up questions - can you take your Core EM in slot as your earliest open elective and just push the elective back? Does your school require that you take EM at your home institution first before you can do aways?

How are current 4th years managing to apply? Them and your EM advisor are going to be your your best source of info.

good questions. im not sure if the EM core is a prerequisite before I can do other aways. I will ask my coordinator. I have been reaching out to current ER residents from my school about this process, because I dont get a lot of info from the school about any of this. thanks for the input

 

[mancub]

If your school lets you, I would say just apply for the 4th year sub-i's to fill your 3rd year elective blocks. You have to prove that you've taken core 3rd year clinicals but no one requires you to prove you are officially a 4th year.

 

[Hamhock]

Listen to your elders.

That's not the advice I would typically give, but in the EM-CCM or EM-IM world, I think it's good advice. Look at the positions of the EM-IM docs; also the EM-CCM docs.

Where do you want to be? Why?

As great as it would be, there is no EM-IM-trauma-anesthesiology 6-year residency.

You will not always be pleuripotent.

HH

 

[boolin_1]

Listen to your elders.

That's not the advice I would typically give, but in the EM-CCM or EM-IM world, I think it's good advice. Look at the positions of the EM-IM docs; also the EM-CCM docs.

Where do you want to be? Why?

As great as it would be, there is no EM-IM-trauma-anesthesiology 6-year residency.

You will not always be pleuripotent.

HH

I gotta say that I wasn't expected to be talked out of it lol. But I will be doing some soul searching and some research about if I want to really do it