Is community better?

[LotaPower]

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I've heard and some of the stigma against community EM programs...many say that they are very benign, low volume etc. I was having a talk with a friend of mine who is also interested in EM. He spent some time in the ER at an academic center and he mentioned that the ER would consult for almost everything. For example, anytime a hip came in, they would call the ortho residents to reduce it. traumas were wisked away by surgery and anesthesia, etc.
since there were a lot of different residents in numerous specialties at that hospital, the ER docs didn't get as much "hands on" experience as he thought they would get.

Does anyone know if this is the case in many EM programs? Do you think community EM programs might provide a more "hands on experience" considering that they are less likely to have tons of residents in other specialties?

 

[JudoKing01]

I would tend to think so. But then again, I tend to be a *****, so take it with a grain of salt.

 

[peksi]

As wth any program things do vary from place to place. I will only speak directly about our program.

At CCHS we see now about 140K ED vistis, The residents do spend some time at our affiliate peds ED, though we se peds on a daily basis as well, this brings the total to about 165,000 ED patient volume for their exposure. We do all airway, reductions, concious sedation, perform over 5,000 EUS per year. We work very well with trauma and other consultants.

As a non-university based program we do have some perks that others might not get, but i would not say things are "cush" considering our patient volume, acuity etc. As a private group we believe our administrative experience and education for our residents is second to none. If you have other questions i'd be happy to answer via PM.


Paul

 

[WilcoWorld]

Your assesment has a lot of truth to it, but things are very program-dependant. So you'll need to evaluate each program on an individual basis. It's good, however, that you realize there are some very good community based EM programs out there where the clinical training is top-notch.

 

[bartleby]

The real value in working in an academic medical center is that it's a referral site for other hospitals. In the average community hospital, they might see 1 or 2 acute aortic dissections in a year. But if 10 hospitals send 2 each to your place each year, you're going to see a lot more interesting pathology. As the academic centers also have more transplant, dialysis, hemo-onc patients, etc. you tend to have a significantly higher rate of acuity. As an EM resident, you need to go where the sick patients are.

As far as procedures go, the housestaff is so overburdened in the admitting services that if you decide you want to do that paracentesis yourself at the end of your shift and you've got your other patients dispo'ed, you're not going to get much of an argument from the admitting resident for reducing his or her workload. Same goes with ortho...they've never bitched me out for doing a hematoma block and reducing my own Colles fractures....

 

[sunnyjohn]

Q?

What facility is CCHS? What state?

This is an interesting thread.

 

[FoughtFyr]

I've heard and some of the stigma against community EM programs...many say that they are very benign, low volume etc. I was having a talk with a friend of mine who is also interested in EM. He spent some time in the ER at an academic center and he mentioned that the ER would consult for almost everything. For example, anytime a hip came in, they would call the ortho residents to reduce it. traumas were wisked away by surgery and anesthesia, etc.
since there were a lot of different residents in numerous specialties at that hospital, the ER docs didn't get as much "hands on" experience as he thought they would get.

Does anyone know if this is the case in many EM programs? Do you think community EM programs might provide a more "hands on experience" considering that they are less likely to have tons of residents in other specialties?

Remember that the RRC measures programs on a "skills driven" basis. That is a program must demonsrate an average of x number of procedure x by the graduates of the program. So, while as a medical student your friend might have had patients "whisked away", as a resident this will unlikely be the case. Given this insured equity by the RRC I looked at three factors when assessing programs, which led me to an academic program (but I think I would have been happy at an urban program as well). 1. Many community programs have to send their residents elsewhere for specific rotations (OB, trauma, and anesthesia come to mind) to insure that the RRC's numbers are met. I prefer to stay at my "home" institution. 2. When at an academic institution you learn the procedures from non-EM residents and attendings. For example, I reduce shoulders with an orthopod in attendance. This gives me a different prospective when developing my own practice style. 3. Moonlighting or Community ED electives can give you the "experience" of a community ED. An academic institution or urban tertiary center is far more difficult to adjust to (in my opinion). I feel comfortable that I can go from an academic instition to practice anywhere. I didn't have that same confidence from a community program.

As for my own biases, I am at a very academic program (Mayo). I rotated as an MS4 in an Urban ED (Wishard County in Indianapolis) and a community program (Resurrection in Chicago).

- H

 

[Sessamoid]

Q?

What facility is CCHS? What state?

This is an interesting thread.

Umm... did you even glance at his .sig line?

 

[peksi]

I think that a great deal of power is placed on the terms "academic" versus "community". What I believe is really meant here is "university", versus "university affiliate or community". If what one means by "academic" is research, publishing, faculty with national recognition and appointment, and cutting edge medical care and education, then it is CRITICAL to realize that some community, non-university based programs meet or surpass many univeristy based programs using these criteria.

Please do not be missled to presume or assume that a university based program provides better education or training. I think Foughtfyr's comments should be considered, in that large tertiary refferal places have their benefits, but as for community based programs, such as ours that is a large tertiary refferal center, I would be surprised to find most "university programs" that can report what we at CCHS have:

-3,000 major traumas per year
-Avg of 2 rutured AAA per month! With over 1500 AAA identified per year
-150 aortic dissections in 5 years
-7,000 liver births
-A primary ED volume 2-3X most university based programs
-Private group buisness education
-Community and inner-city hospitals
-Oh and tax free shoping!
-Avg door to cath time for AMI at 64 min that is 36% faster than the national average, and that is for about 250 AMI patients per year
-Graduates who have done fellowships in Ultrasound, Tox, Em/Critical Care, EMS, Research, and Admin
-Support 2 full time EM research nurses

and the list goes on,

My only point here is that just as students should see 3 year versus 4 year programs for themselves. be sure to do you homework, and look for the program that fits you bes! Find the place that for the next 3-4 years you will be excited to wake up and go to, cause you WILL BE THERE ALOT, and avoid specific generalizations.

I do realize that interview season allways approaches quickly, if you are not sure "how many" programs to apply to or which to apply to, you can always just call a program, tell them you are a MS interested in EM and ask to shaddow a resident, or attending to see the program. Even prior to interview applications or season.

I hope this did'nt seem like a rant,I just wanted to give strong "non-university" based programs such as ours their props!

Best of luck
Paul

 

[Hayduke]

I do realize that interview season allways approaches quickly, if you are not sure "how many" programs to apply to or which to apply to, you can always just call a program, tell them you are a MS interested in EM and ask to shaddow a resident, or attending to see the program. Even prior to interview applications or season.

This sounds like a great idea. With the consensus of 2 elective rotations being the reasonable limit for auditions, I have wondered how one gets a "feel" for different programs.

As a student in the Northeast looking for programs at some distance (W/SW/SE) is this a reasonable plan? Are there other programs that facilitate these "shadow" sessions?

 

[peksi]

As a student in the Northeast looking for programs at some distance (W/SW/SE) is this a reasonable plan? Are there other programs that facilitate these "shadow" sessions?[/QUOTE]

My thoughts would be as follows: after you select your away rotation at an ED in your intended local, type of prorgam etc. Just email orcall the program, tell them you are in the area and ask to shaddow. That's how I did it, and I did not recieve a negative from anyone. If your issue is then needing to stay over many residents are willing to offer you a spot on the floor, etc, if you are so inclined, often an email to the Chief residents can aid in this type of info. You really do want to see a program at "night", and can give great insight into the functioning of the department when the admin folks are not around.

Paul

 

[docB]

-7,000 liver births

Good Heavens! I've never even seen one and you guys have seen 7000?! How does an impending liver birth look on US. Does the hepatic duct stretch all the way down to the uterus? When it all comes out how do you tell the liver from the blood clots? Does the GB stay intact? Wow! 😛

Note- I'd ordinarily never poke fun at someone's typo 'cause God knows I've dropped some whoppers on here but this was just to good to pass up. I know Peski will understand. It's the visual I get thinking of a liver birth. Kind of like the scene from Alien. Eeeewwww!

 

[peksi]

Good Heavens! I've never even seen one and you guys have seen 7000?! How does an impending liver birth look on US. Does the hepatic duct stretch all the way down to the uterus? When it all comes out how do you tell the liver from the blood clots? Does the GB stay intact? Wow! 😛

Well usually the GB is intack, however if it does impede in delivery of the liver then the rarely ever discussed and dreaded "cholestatic maneuver" is employed! You need the assistance of any highly fatty food and coax that PIA GB out of the way so you can finish the delivery!!!!!

As for destinguishing liver from clot that is based on the acoustic impedance of course!

Paul

 

[FoughtFyr]

I think that a great deal of power is placed on the terms "academic" versus "community". What I believe is really meant here is "university", versus "university affiliate or community". If what one means by "academic" is research, publishing, faculty with national recognition and appointment, and cutting edge medical care and education, then it is CRITICAL to realize that some community, non-university based programs meet or surpass many univeristy based programs using these criteria.

Please do not be missled to presume or assume that a university based program provides better education or training. I think Foughtfyr's comments should be considered, in that large tertiary refferal places have their benefits, but as for community based programs, such as ours that is a large tertiary refferal center, I would be surprised to find most "university programs" that can report what we at CCHS have:

-3,000 major traumas per year
-Avg of 2 rutured AAA per month! With over 1500 AAA identified per year
-150 aortic dissections in 5 years
-7,000 liver births
-A primary ED volume 2-3X most university based programs
-Private group buisness education
-Community and inner-city hospitals
-Oh and tax free shoping!
-Avg door to cath time for AMI at 64 min that is 36% faster than the national average, and that is for about 250 AMI patients per year
-Graduates who have done fellowships in Ultrasound, Tox, Em/Critical Care, EMS, Research, and Admin
-Support 2 full time EM research nurses

and the list goes on,

My only point here is that just as students should see 3 year versus 4 year programs for themselves. be sure to do you homework, and look for the program that fits you bes! Find the place that for the next 3-4 years you will be excited to wake up and go to, cause you WILL BE THERE ALOT, and avoid specific generalizations.

I do realize that interview season allways approaches quickly, if you are not sure "how many" programs to apply to or which to apply to, you can always just call a program, tell them you are a MS interested in EM and ask to shaddow a resident, or attending to see the program. Even prior to interview applications or season.

I hope this did'nt seem like a rant,I just wanted to give strong "non-university" based programs such as ours their props!

Best of luck
Paul

I absolutely agree 100%. And I suppose my diction leaves something to be desired. Please substitute "tertiary" anywhere I stated "urban" or "academic". I took the OPs question to relate to smaller, community based EM programs as he/she seemed concerned that at a larger center the patient would be "whisked away" by other, non-EM residents for procedures. I was trying to relate that, in my opinion, this did not happen at most large facility EM programs. I also feel strongly that it is far easier to move to a smaller volume ED from a tertiary center after residency than it is to do the opposite.

I was speaking more to volume and size than to administrative structure. And by no means am I trying to slight any program. I personally felt that training in a large institution would keep the most doors open to me later in my career. That is not to say that this is true for everyone, nor is it meant to slight programs at smaller institutions. And much as Dr. Sierzenski points out, there is a wide variation in programs and their structure. While Chirstiana is technically "community based" it is as large and busy as most urban or academic centers. There are also big institutions that support (relatively) small EM residencies. It is, as has been {singing} said many times, many ways {o.k., I'm stopping} all about finding the right fit for you.

- H

 

[deleted59964]

Well usually the GB is intack, however if it does impede in delivery of the liver then the rarely ever discussed and dreaded "cholestatic maneuver" is employed! You need the assistance of any highly fatty food and coax that PIA GB out of the way so you can finish the delivery!!!!!

Paul

I hear CCK is the agent of choice in emergent GB reduction for hepatic delivery.