Graduating EM resident - ask away, anything

[deleted109597]

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1) How often do EM doctors write prescriptions? If so, do you have your own pad or do you use computers to print the prescription and sign it?

Roughly half of discharged patients get scripts. The computer prints them out at all the places I've worked, but there is paper backup.

2) In cold weather, do many people use thermal pants under the scrubs?

No, I work inside. I also don't wear scrubs most of the time.

Thank you, Dr.McNinja, for your answers. I was actually wanting to know more about how this will effect the attendings' lives, salaries, work environment quality, and satisfaction in these groups as this happens.

Working for a corporate group has not made one difference in how I feel at work, and has no effect on my home life. The big groups are usually independent contractor, so you need someone who can do your taxes. As far as the quality of the work environment, the group can't control the nursing, or the CMO, or many other things. They may attempt to influence it, but it's a separate set of rules. Most of us are satisfied, and the benefit of being in a bigger group is that when someone is sick, there is a bigger pool of people to pull from. Truly it all comes down to not dreading to go to work. You can have a great group and a terrible hospital, or a great hospital and a terrible group, and all variations in between. It is up to each individual to figure out what is best for them.

 

[pinipig523]

Can you give an example of one of your negative experiences with the people bolded above? I'm trying to get a sense of what I may have to put up with.

Scum?

The heroin addict that you saw in the corner of the street when you were coming into work who was panhandling for money - is now in your asthma room and steals your albuterol inhalers and absconds only to sell it outside the ER.

 

[American Shero]

Scum?

The heroin addict that you saw in the corner of the street when you were coming into work who was panhandling for money - is now in your asthma room and steals your albuterol inhalers and absconds only to sell it outside the ER.

I've worked a few jobs in retail in really bad neighborhoods where something like this would often happen. After the initial shock and disappointment, I learned to laugh it off.

Anywhoo.. Thanks for the responses. I'm definitely considering em, and I was just trying to figure out if it's any worse than what I've dealt with in previous jobs. Luckily, I'm already jaded and I stopped believing that people were inherently good years ago, so I'm hoping that will help to ease the blow.

 

[beanbean]

I am an ED attending in the Northeast and graduated residency this past year. I am also a nontrad who went to medical school when I was 35.

I love my job. I went to med school with plans to become an EM doc and didn't change my mind...which is unusual.

What I love best is that no day is ever the same; I learn something every shift. What I learn may have nothing to do with medicine, but I always learn something new. We see people at their best and their worst. We see people of all ages, races, socioeconomic levels. No one is turned away...at least until they have been evaluated and had a medical screening exam. In the last month I have treated patients between the ages of 0 seconds to 102+years. Some physicians enjoy having a niche specialty where they can know everything there is to know about one aspect of medicine. Those of us in EM are the opposite. We thrive knowing a little bit about everything. Not that we aren't experts, we are experts in resuscitation and diagnosis. We are really good at sensing who is sick, really sick, and taking immediate action to intervene. Some people say we are just glorified triage nurses. We just decide who to admit vs discharge and call the real doctors to treat the patient. However, it is so much more than that. Managing an ED and it's ever changing population of patients while determining the correct diagnosis and interventions is a real art. Throw in a few patients who are actively trying to die and you'll see what we excel at.

Some of the practical stuff from my point of view:

EM is shift work. It is not the field for you if you want nights and weekends off.

Part-time work is possible and not difficult to find.

Full time in my group is about 110 hours per month. Most of us work 102-150 hours per month.
We are paid hourly and get bonuses based on patient satisfaction score (Press-Ganey) and RVUs (weighted calculation of patients per hour. As a group partner you also receive bonuses based on the group's profit.

Coverage ranges from 1 doc and 1 PA overnight to 3 docs and 1 PA during the afternoons.

EM has a mix of MD and DO's. I know some of my colleagues are DO's but I'm not sure exactly who. This is reality...we are all doctors and no one cares if someone is a DO unless you are on SDN. Very few specialties may be different but in EM there is no stigma.

Besides the "normal" patients we also frequently deal with drunk/high people, people with profound mental illness, sociopaths, manipulators, drug seekers, narcissistic people, abusers, the abused, and the family and friends of all of there above. You need to be the kind of person who can function in these interactions and not take things personally. This is true for all fields of medicine but it is much more so for EM.

3yr vs 4 yr residency: Try to match at the program you like the best. You don't need a 4th year to be a good EM doc, but if you are going into academics a 4 yr program amy be more suitable for you. 4 year programs do offer more elective time/research. If this is important to you then focus on 4 yr programs. There are plenty of 1-2 year fellowships in EM. If you are particularly interested in one of these areas (international med, hyperbarics, toxicology, ultrasound, EMS, etc) a 3 yr program +fellowship may be your best route.

This is a great thread!

 

[Cinclus]

This is a great thread!

Yes it is! Thank you for your additional comments, and thanks to pinipig for creating the thread and providing so many answers. It's been an enlightening read.

 

[pinipig523]

Yes it is! Thank you for your additional comments, and thanks to pinipig for creating the thread and providing so many answers. It's been an enlightening read.

Thanks guys... and thanks to the attendings who commented on this thread. I still have much to learn. 👍

 

[BirdIsTheWord]

This is what I love about SDN. Having all of the different levels of medicine involved in helping one another and providing insight into the field.

Thanks pinipig and others for the great questions and even better answers

 

[Spatula]

Thanks to the OP and all the other EM posters. Definitely makes me think that EM isn't my cup of tea but still very interesting. Hope some other specialties would start similar threads.

 

[kautionwirez]

Here's an interesting question:

Do you know anyone who had a Step 1 score of 260+ or 99% that went into Family Medicine or a specialty that has a low step 1 average?

Out of curiosity sake...

 

[propadex]

I would say, "Self... keep reading, keep reading, keep reading, keep doing questions, keep furthering your knowledge."

It's that simple for me. I'd be smarter than I am now. I've been really reading a lot for the past year and I should've kept this pace up for much longer.

When you say reading, do you mean..scientific journals/articles relevant to your field and interests? Any advice or recommendations for those of us entering medical school next year who already possibly feel an inclination or draw towards EM? Thanks! This thread has been super inspiring.

 

[sgtbrushes]

I'm matriculating into med school next year, with my top interests being peds and/ or EM and/ or peds-EM.
(1) Any idea how competitive a peds-EM fellowship is?
(2) I have heard (just scuttlebutt, not from any professionals) that the vast majority of peds-EM fellowships go to peds residents, not EM residents. True/ not true?
(3) From an RN friend: "Peds EM is just a bunch of asthma attacks and runny noses." (Obviously exaggerated, but how much?) From your experience on the peds side, is there still a good amount of "diagnostic variety" compared to adult EM (obviously you don't have the same stuff as adults, MIs, COPD, etc.)?

 

[beanbean]

As you know there are two ways to go into Peds-EM.
Peds residency (3yr) +fellowship (3yr)
or
EM residency (3 or 4 yr) +fellow ship (2yr)

It is more common to do peds residency and then specialize but you certainly can do the EM residency route. It really depends if you want to see adults at all. To be EM-Pedi-EM you can still work as a regular adult ED doc. Conversely, if you might ever want to do straight peds or another peds fellowship - go the peds route.

There certainly are days when it seems like peds EM is all runny noses and otitis, but for cases when kids are really sick I think peds EM can be a very satisfying field. The RN you know who stated it's all just runny noses and asthma attacks should realize that part of peds EM is recognizing and respecting asthma. Having the training and gut instinct to know which kid is having their regular mild asthma attack vs the kid that is going to decompensate and code in front of you is why peds EM folks can be invaluable. Not that you don't get peds training in an EM residency, but depending on where you work taking care of sick kids can be a rarity.. Do electives in both as a med student and hopefully your path will be clearer.

 

[sgtbrushes]

Thanks, Timon!

 

[BurntFlower]

1. We've had some residents who went on to do fellowships in International Medicine and some who volunteer a great amount of time to clinics at 3rd world countries.

2. When I become an attending, my plan is to have ample vacation time to go and travel.

Thank you for the reply! I have some more questions:

As EM residents/physicians, where do they find the time to volunteer to other developing countries? I am interested in being part of Doctors Without Borders at some point, but is it doable with the amount of debt one gets in?

 

[ArmyWife1153]

Here's how I'd do it. Take a good paying job in the community. Make approx 375K, put in 64K into the 401K, invest VERY conservatively to avoid pitfalls. At age 59, I'd have approx $6,000,000 at avg return of 4%/yr.


.

Are you putting $64k into a 401k every year? Is that with employer match or one you set up?

 

[ArmyWife1153]

I am interested in being part of Doctors Without Borders at some point, but is it doable with the amount of debt one gets in?

I can tell you what I've found from my research as I also want to do MSF.
You can't do MSF until you complete residency. That is one of the hiring requirements.
You will get matched more quickly with a position with MSF if you are in one of their current urgent specialities (obviously this changes as the need does) and you are willing to go for the standard 9-12 months.
You get paid around $1400/month with in country room and board.

I thought about doing it right out of residency before starting a job, but I think now I may actually do it once I'm financially comfortable and could reasonably take that kind of leave.

 

[whatbout2morrow]

What would you say to someone who is interested in emergency medicine yet has a fear that he/she may freeze up/forget to follow protocol at the worst possible time ultimately resulting in a patient's death?

 

[jdok]

What would you say to someone who is interested in emergency medicine yet has a fear that he/she may freeze up/forget to follow protocol at the worst possible time ultimately resulting in a patient's death?

Become a nurse.

 

[OzelloPiRat]

Become a nurse.

I was going to respond to the "nurse" comment, but will let the big dogs handle it.

 

[fletchffletch]

Thank you for the reply! I have some more questions:

As EM residents/physicians, where do they find the time to volunteer to other developing countries? I am interested in being part of Doctors Without Borders at some point, but is it doable with the amount of debt one gets in?

I can tell you what I've found from my research as I also want to do MSF.
You can't do MSF until you complete residency. That is one of the hiring requirements.
You will get matched more quickly with a position with MSF if you are in one of their current urgent specialities (obviously this changes as the need does) and you are willing to go for the standard 9-12 months.
You get paid around $1400/month with in country room and board.

I thought about doing it right out of residency before starting a job, but I think now I may actually do it once I'm financially comfortable and could reasonably take that kind of leave.

I just recently read an AMA on reddit.com with someone who used to volunteer with MSF, and he said he never worked with a single US MD. Not that there weren't any, just none in his group, and not a lot in general.

"most of our doctors were English or Australian because they could take a lot of time off work (without the risk of losing their job) and they didn't have to pay back astronomical loans."

 

[mdhopeful65]

is it ever a problem that as a ER doc, you work for a boss, and may be fired at any moment? A relative of mine is a ER doc and was fired after 25 years at a hospital because he was "too slow" in seeing patients, compared to the newly minted grads who wouldn't mind seeing 30+ patients daily.

 

[RavishingB]

Thanks for answering all our questions, this thread should be stickied!

What is the most ridiculous/funny CC that had you thinking "Seriously?!?" lol.

 

[pinipig523]

Here's an interesting question:

Do you know anyone who had a Step 1 score of 260+ or 99% that went into Family Medicine or a specialty that has a low step 1 average?

Out of curiosity sake...

I had a classmate who score 263 on Step 1, did not match urology, went into FP/Primary Care.

 

[pinipig523]

Thanks for answering all our questions, this thread should be stickied!

What is the most ridiculous/funny CC that had you thinking "Seriously?!?" lol.

Nightmares. Someone called 911 for nightmares. 😀😀😀

 

[pinipig523]

is it ever a problem that as a ER doc, you work for a boss, and may be fired at any moment? A relative of mine is a ER doc and was fired after 25 years at a hospital because he was "too slow" in seeing patients, compared to the newly minted grads who wouldn't mind seeing 30+ patients daily.

I suppose that would be a possibility. As with any employed position, you are the mercy of your production/quality of services.

Even as a boss of a private practice in any other specialty, your actions may have indirect consequences on either your practice's stability or financial revenue. You may not be "fired" but you may still lose more and more money as you become less and less productive.

 

[pinipig523]

What would you say to someone who is interested in emergency medicine yet has a fear that he/she may freeze up/forget to follow protocol at the worst possible time ultimately resulting in a patient's death?

You need more training.

 

[moxche]

Thanks so much for doing this thread.

Could you comment on the frequency, amount of time, and general impression of non-patient-care things that you did during your residency? (Things that come to mind: lectures, research, conferences, committees, simulation exercises, etc.)

You missed mine

 

[DocGodfather]

The ER rocks and thank you to the two ER docs that have taken the time to give us information! If I'm lucky enough to get into medical school, I'm looking at EM or oncology. 👍

 

[EM_Rebuilder]

This is one awesome thread and I am glad to see if was started by one of the EM folks!!

I see that DrMcNinja has jumped in, and I dont want to hijack the thread but I will keep an eye on this and try to answer some questions also.

I am my first year out of a 4 year program; from Texas, trained in MS, and now back in Texas. Many great questions with excellent answers have been poised in this thread. I could not agree any more with how awesome Emergency Medicine is. I make insane amounts of money; have all kinds of time off, and have a GREAT time while at work. Whoever knew life could be so good?

People in Emergency Medicine are awesome also. The other two EM people in this thread, I have never met in person, but have had some private messages about various topics. Most people in EM are friendly, open to dicsussions, and tend to be really enthusiastic about our specialty. I like to think that the warm welcomings you see in this thread is a model of the typical EM physician!

 

[BurntFlower]

I just recently read an AMA on reddit.com with someone who used to volunteer with MSF, and he said he never worked with a single US MD. Not that there weren't any, just none in his group, and not a lot in general.

"most of our doctors were English or Australian because they could take a lot of time off work (without the risk of losing their job) and they didn't have to pay back astronomical loans."

That is why I hope an EM attending will answer my question if they know anyone that has done Doctors Without Borders and how they did it. I really want to be part of this organization in the far future, but I don't know how I'll do it with the amount of debt I'll be getting into.

 

[Cooperd0g]

You missed mine

Throttle back the entitlement attitude. This guy is doing us all a favor by answering our questions in an honest and forthright manner. If you feel he missed your question, just ask it again ... politely.

 

[American Shero]

Throttle back the entitlement attitude. This guy is doing us all a favor by answering our questions in an honest and forthright manner. If you feel he missed your question, just ask it again ... politely.

😏

 

[jdok]

Throttle back the entitlement attitude. This guy is doing us all a favor by answering our questions in an honest and forthright manner. If you feel he missed your question, just ask it again ... politely.

lol who do you think you are? If you want to be someone's dad, go knock up some random hood rat. In the mean time, please don't try to police this thread. The dude's comment was just bringing up his previous question.

 

[deleted109597]

That is why I hope an EM attending will answer my question if they know anyone that has done Doctors Without Borders and how they did it. I really want to be part of this organization in the far future, but I don't know how I'll do it with the amount of debt I'll be getting into.

I don't know anybody that does it. It is fairly uncommon for people in this country because of MSF's requirement for the amount of time. It is better for them, as you can't make much difference in 2 weeks. However, most jobs aren't cool with you spending a year not working.

Could you comment on the frequency, amount of time, and general impression of non-patient-care things that you did during your residency? (Things that come to mind: lectures, research, conferences, committees, simulation exercises, etc.)

4 hours of lecture, 1 hour of "dissynchronous learning" every week (except Christmas and ACEP). Not on a committee. You probably go to at most two conferences during your residency, unless you do a lot of research and get posters/talks accepted at others. Sim exercises are done during lecture.
Most weeks go by without any research, and most EM people don't do research outside of their required project.

 

[EM_Rebuilder]

Thanks so much for doing this thread.

Could you comment on the frequency, amount of time, and general impression of non-patient-care things that you did during your residency? (Things that come to mind: lectures, research, conferences, committees, simulation exercises, etc.)

I'll answer..

Some of this is program dependent; however there is a baseline required by the RRC...

5 hours of conference time attended 70% of the time (again, some programs may require a higher percentage so there is a buffer).

Lectures, you will probably have to give 'some' lectures. Probably approx 2 a year. Again, that is slightly program depedent.

Every resident must complete a 'scholarly project'... that is open to interpretation; I assure you not ever single resident publishes a paper... Some might start some research, gather data, some might put together an EKG review book and give it to the other residents.. again most programs treat this pretty liberal..

National Conferences... again, program dependent. My program gave every resident 'one trip regardless'... my entire senior class went to ACEP in Las Vegas. Additional conferences were paid for if you presented/had papers in them.

Simulation depends on the program and how involved the program is in it. I think there are some programs with zero simulation; others are the state of the art centers. We had simiulation probably once a semester; it was counted as 'conference time'...

Committee membership again would be program dependent. At ours, it was an application and voted on by your peers.

Chief residents do tend to have more to do outside of the hospital. I was a chief and did have several meetings each month, occasional 'on the fly' meetings with the PDs, additional lectures, meetings with other departments, etc. This was part of the 'chief thing' and I did work a few less shifts to help compensate the time spent.

With all that said... its hard to put an exact time commitment on it. You also will have some studying to do within all this mix.

Some of the stuff you have to do are simply 'hoops' that you have to jump through. You will have some awesome lectures and probably some crappy lectures. Sometimes your reasearch project may end up sucking because you scramble to just do something in order to graduate.

I wont say outside stuff is all fun and games, but this stuff continues somewhat into attendinghood; albeit some of it is more elective. On Monday I have to do my ATLS refresher course; tomorrow I am going to Trauma M&M for 2 hours. On thursday of this coming week, I have to go to a Sedation Committee meeting.

 

[beanbean]

There are many organizations for international work besides MSF and I know quite a few medical folks who do international medicine regularly. It is definitely easier to make international medicine part of your life due to the flexibility of EM scheduling and locum tenums work. You should look at residencies that allow an international elective during residency and that have faculty with international connections. It may be possible to do an international elective in med school as well.

 

[chidoman]

How often (what percentage) can you make the diagnosis solely on physical exam/history?

That being said, how often do you/your colleagues order labs to "cover your butt" when you know it isn't needed?

I ask as a med student seriously interested in EM. A non-academic EM physician told me the other day that he wished that in med school they taught him how to practice "cover your butt medicine", ordering labs/MRI's ect. purely to cover all the bases in case he goes to court. Also one of my MD instructors says "there is no such thing as routine labs even though that's what they do in the ED". and "that's bad medicine".

I'm curious to know your opinion on the matter. I'm not trying to be negative, the EM docs I've been with have all practiced "good medicine" in my opinion.

Thanks so much for the time put into this thread, its amazing!

 

[CeeEstee0]

Sorry if these have been asked before, but I skimmed the thread and didnt see them.

-Would an EMT course be worth taking if i am interested in EM?

-What do you know about sports medicine fellowships, (salary, job opportunities, how competitive), etc.

And, even though everyone has said this, thank you for taking time to answer our questions.

 

[beanbean]

An EMT course is great if you are going to use the training by volunteering or working as an EMT or ED tech. Just taking the class is a waste of time and money.

Sports Medicine is not a common fellowship for people to do in EM. Perhaps some of the others know someone who has but I do not.

 

[Docforthepeeps]

Since you work in Cook county hospital, I am sure you interact with a lot of Ros Franklin students. I had an interview there recently. What are your thoughts about how their students did in the rotations/internships/as residents etc compared to students from other schools? Do you feel that they were trained adequately?

Thank you so much for your answer. I appreciate it.

P.S: Thank you to the wife too for letting you spend your free time answering questions on SDN 😀

 

[deleted109597]

How often (what percentage) can you make the diagnosis solely on physical exam/history?

Less than half. However, I can often make the decision to admit on well over 75% based on the HPI.

That being said, how often do you/your colleagues order labs to "cover your butt" when you know it isn't needed?

On nearly every patient. Our job is held to a different standard than outpatient docs. We are there to rule out any life threatening emergencies. Thus, even a 1% chance of a miss is too much.

I ask as a med student seriously interested in EM. A non-academic EM physician told me the other day that he wished that in med school they taught him how to practice "cover your butt medicine", ordering labs/MRI's ect. purely to cover all the bases in case he goes to court. Also one of my MD instructors says "there is no such thing as routine labs even though that's what they do in the ED". and "that's bad medicine".

It is bad medicine. But it is good defense. Until we fix the legal system, we have to play by their rules.

Sorry if these have been asked before, but I skimmed the thread and didnt see them.

Then read it all at some point

-Would an EMT course be worth taking if i am interested in EM?

No

-What do you know about sports medicine fellowships, (salary, job opportunities, how competitive), etc.

They are heavily biased towards FM and Ortho. Just a fact of the matter. Also, the job opportunities are either volunteering at local HS sports, or paying to be a sponsor of a pro team. Nobody pays doctors to see their players. The doctors pay to be the team's physician, because it is advertising.

 

[chidoman]

Thanks Dr. McNinja!!

 

[Hamiltonian]

I have seen some Family Med docs working in the ED. This is common? How do you think they would do things differently than someone that went through an EM residency?

 

[JackShephard MD]

Here's an interesting question:

Do you know anyone who had a Step 1 score of 260+ or 99% that went into Family Medicine or a specialty that has a low step 1 average?

Out of curiosity sake...

11 of 1100+ US seniors had a score of 260+ last year that matched into FM.

I think you have to keep in mind that a 260+ takes lots of work and high scores aren't required for FM. Therefore, these individuals will be less likely to prep as well as individuals who feel they need a 250+. Not sure why this would be interesting.

 

[JackShephard MD]

Here are some questions for EM attendings:

1. At what age do you think you will need to step down from full-time practice as an EP?

2. How many years do you think you think you can practice EM?

3. Do you feel like not being able to offer definitive care often lowers your career satisfaction (i.e. diagnosis and consult)?

4. Do you feel like you're making a difference? Are you passionate about your career or is it just a job to earn income?

5. How will EM protect itself from looming cuts?

6. Do you feel like your contribution in our healthcare system is essential and difficult to replace?

 

[EM_Rebuilder]

Here are some questions for EM attendings:

1. At what age do you think you will need to step down from full-time practice as an EP?

2. How many years do you think you think you can practice EM?

3. Do you feel like not being able to offer definitive care often lowers your career satisfaction (i.e. diagnosis and consult)?

4. Do you feel like you're making a difference? Are you passionate about your career or is it just a job to earn income?

5. How will EM protect itself from looming cuts?

6. Do you feel like your contribution in our healthcare system is essential and difficult to replace?

1. Financially or physically. At the rate I am going, I think I can easily retire after 15-20 years of practice and live VERY comfortable. Physicially, I think I can go longer than that. I think you can essentially go forever as long as hours are cut back. I do not care to be 70 and work 15-12s. I could see myself being a typical healthy 70 year old and still working 'a couple shifts a month'. In reality, I hope to live in the middle of hundreds of acres and hunt/fish and hang out with my grandkids.

2. Sort of already answered above. To add... I think I would not work as hard in 20 years as I will the next 5... there just is no need for it. I can work less than 4 shifts a month right now and make into a six figure income...

3. This is a big ignorance of our job. I assure you I see/treat/diagnosis way more patients than I simply consulted out for the diagnosis. I also diangosis many disease and give to other consultants for continued care. We diagnosis more MIs than Cards, Appys than Surgery, etc.

4. I think I(we) as a speciality make a difference. I have worked/moonlit in places where old retired OB/Gyns and Surgeons generally 'ran the ER'... those places had very poor quality. When like minded EM trained, or the older folks that practiced many years, run an ED.. I think state of the art emergency care happens and lives get saved.

5. Hard for me to answer; I am still young and perhaps naive yet. Our speciality is generally not a money maker per se for the hospital, but does serve as the 'front door' for greater than 50% of the patients in the house.

6. Yes, I think trained EM physicans play a vital role in healthcare. I have had more than one private consultant say they appreciate the fact of XYZ and I think many of these instances came from my (our) EM training...

 

[Fedekz]

-Would being a paramedic (not an EMT-basic) increase your chances on matching into EM? Or getting into medical school for that matter

-Do EM residents/attendings see paramedics as a cab ride for the sick, or do they know we can actually do quite a bit in the back (RSI, integrilin, heparin, etc)

The reason I ask is because I've been working as a paramedic for 1.5 years now.

Thank you!

 

[pinipig523]

-Would being a paramedic (not an EMT-basic) increase your chances on matching into EM? Or getting into medical school for that matter

-Do EM residents/attendings see paramedics as a cab ride for the sick, or do they know we can actually do quite a bit in the back (RSI, integrilin, heparin, etc)

The reason I ask is because I've been working as a paramedic for 1.5 years now.

Thank you!

1. I think being a medic may slightly increase it if you worked it, but it's not a significant jump through the rank list.

2. I did an EMS rotation last week and I intubated someone and ran the code at the back of the ambulance. So, yes, we know what you guys do. We are taught this in residency.

 

[pinipig523]

I have seen some Family Med docs working in the ED. This is common? How do you think they would do things differently than someone that went through an EM residency?

I have not yet worked with them in the ED, but I have been told that there is definitely a difference.

 

[xBODOMx]

.