Keeping current as an attending

[sylvanthus]

Question for the attendings out there. What do you guys do to keep current and/or knock out your CMEs? EBMedicine, EMReports, Critical Decisions, EMEDHome, EMRAP, EMCRIT? Seems there is a plethora of possibilities as an attending, but its all way more friggin expensive now than being a resident/fellow. Trying to do what I can do stay on top of my **** and not spend an arm and a leg.

Any thoughts appreciated.

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[miacomet]

Question for the attendings out there. What do you guys do to keep current and/or knock out your CMEs? EBMedicine, EMReports, Critical Decisions, EMEDHome, EMRAP, EMCRIT? Seems there is a plethora of possibilities as an attending, but its all way more friggin expensive now than being a resident/fellow. Trying to do what I can do stay on top of my **** and not spend an arm and a leg.

Any thoughts appreciated.

Make your job pay for it- most attendings outside academia don't do much.

 

[Groove]

I have UpToDate sub that tracks all my searches and gives me 0.5cme per search. I pretty much use that for 100% of my cmes.

I subscribe to Critical Decisions and really like that journal. Some months are higher yield than others but it’s short and sweet and easy to finish unlike most journals.

Most of us get Annals if you are ACEP member. I’ll scan that and select read a few studies that tickle my interest.

I have EMRAP sub but am really bad about not listening to it for a few months and then listening to a bunch during road trips out of town. ( Pretty much the only time so listen to it.)

I bought the new Rosen’s (new to me) a month ago with the intent of scanning through it over the course of next few months but let’s get real...I don’t think I’ve picked it back up since that night lol.

I have a bunch of specialty related books that I read every now and then on radiology or other things but it’s pretty infrequent. The kind of books you buy going “I’ll totally read that..” and 2 years later you’re still “reading” it.

Most of my “reading” is probably case related stuff during work, usually on UpToDate if I get something that is uncommon or unusual.

 

[BoardingDoc]

Question for the attendings out there. What do you guys do to keep current and/or knock out your CMEs? EBMedicine, EMReports, Critical Decisions, EMEDHome, EMRAP, EMCRIT? Seems there is a plethora of possibilities as an attending, but its all way more friggin expensive now than being a resident/fellow. Trying to do what I can do stay on top of my **** and not spend an arm and a leg.

Any thoughts appreciated.

Uptodate frequently for obvious reasons.

Journalfeed for daily bits of info. Anything that seems really poignant is worth reading the actual article, as I've found the journalfeed author's conclusions to be less than reliable on a handful of occasions. That said, it's more useful than not and it's free.

I'm still on my residency journal club mailing list and try to read whatever is being covered most months.

 

[Tenk]

Uptodate. Emrap in the car. One conference a year. Meh!

 

[Paperman]

I'm a newer attending but so far it's been pretty easy. 99% of what I learned during residency still forms the core of my knowledge base.

I used to love EM:RAP, etc. as a medical student and resident but I've found that most topics they cover are either too basic or too novel and not applicable in my system (i.e., I can't be only EM doc in group following Cam Berg's rapid protocols as I'd be a huge outlier and that isn't the way our group, hospitalists, specialists currently practice).

UpToDate is not a great resource for EM practice.
EB Medicine is overly thorough and superfluous and best geared towards interns.
Critical Decisions is pretty good.
Annals and Journal of EM are both OK quick skims.
There are a variety of EM/Critical Care websites I'll peruse infrequently, maybe once every 1-2 weeks, and they're generally redundant so pretty easy to see what "experts" thoughts are these topics. I can usually do this during a shift when bored.

I think you'll find it to be much easier than you think.

TPM

 

[thegenius]

I stay mostly uptodate with a blog reader on my phone. I use Feedly and subscribe to a number of blogs:
(in no particular order)
- Dr. Smith's ECG Blog
- EMCrit Blog
- Emergency Medicine Literature Of Note
- First 10 EM
- LITFL
- The Poison Review
- MD Whistleblower
- Resus M.E!
- The Central Line
- REBEL EM
- The Trauma Professional's Blog
- KevinMD.com

I read this stuff regularly. Primarily while I'm on the shiiter or before going to bed.


While I work I primarily use UpToDate. It's not geared for EM but it's thorough. I would like UpToDate for EM though, which would cut out about 75% of the crap.

 

[thegenius]

By the way, I think the biggest challenge for attendings, especially those in the community, is staying up to date with literature, evidence based medicine, and changing your own practice based on EBM. I work with docs who have been practicing for 25 years, and they practice that way. They have a lot of experience but do stuff real old school.

 

[RustedFox]

By the way, I think the biggest challenge for attendings, especially those in the community, is staying up to date with literature, evidence based medicine, and changing your own practice based on EBM. I work with docs who have been practicing for 25 years, and they practice that way. They have a lot of experience but do stuff real old school.

Things that I've heard old men say at my one job site:

"You can't have a kidney stone if there's no blood in the urine."
"Reflexes are like a poor man's MRI. If they're normal, there's nothing wrong."
"Clindamycin kills Merserrr (MRSA)?"
"If the HCG is below 2000 they're not pregnant."

 

[miacomet]

It's definitely difficult to keep up on stuff. And every place has their own culture- if you stay at one for a long time (rare in EM) you get even more used to doing things one way.

The failure, IMHO, of MOC is that it tries to assess arcane, useless knowledge instead of assuring that diplomates are up to date on the most important new evidence and practices. Ultimately, it's the failure of, and obsession with, test-taking that has led to this. Sure, a test at the end of residency makes sense, but to ensure continued competence (which most docs want to do), a different approach is needed. If ABEM (and every other specialty board) could get rid of useless things like LLSAs and the ConCert and instead create EBM modules that diplomates could work through, they would have happier, better-trained, and more up to date physicians. But that's clearly not their goal.....

 

[deleted547339]

It's definitely difficult to keep up on stuff. And every place has their own culture- if you stay at one for a long time (rare in EM) you get even more used to doing things one way.

The failure, IMHO, of MOC is that it tries to assess arcane, useless knowledge instead of assuring that diplomates are up to date on the most important new evidence and practices. Ultimately, it's the failure of, and obsession with, test-taking that has led to this. Sure, a test at the end of residency makes sense, but to ensure continued competence (which most docs want to do), a different approach is needed. If ABEM (and every other specialty board) could get rid of useless things like LLSAs and the ConCert and instead create EBM modules that diplomates could work through, they would have happier, better-trained, and more up to date physicians. But that's clearly not their goal.....

Dolla dolla bills y’all.

 

[thegenius]

Things that I've heard old men say at my one job site:

"You can't have a kidney stone if there's no blood in the urine."
"Reflexes are like a poor man's MRI. If they're normal, there's nothing wrong."
"Clindamycin kills Merserrr (MRSA)?"
"If the HCG is below 2000 they're not pregnant."

HOLY MOLY.

What is up with the reflexes comment? Where does that even come from? You can have a major stroke and reflexes are normal. LOL

 

[RustedFox]

Dolla dolla bills y’all.

C.R.E.A.M.

 

[thegenius]

You mean like
C.R.E.A.M. O.F. W.H.E.A.T.?

 

[TheComebacKid]

Not an attending. Even as a resident with all these free resources available, keeping up with studying is hard.

I still use WikEM on every single shift. It's on my phone. I haven't opened UpToDate since starting residency, it's too detailed and not even remotely geared towards our specialty. WikEM is a phenomenal resource. Probably not good for "studying" but it's my go to.

Amal Mattu's ECG Weekly is fairly easy to keep up on, especially since the videos are usually no more than ~20 mins, and you can watch it while sitting on the toilet or at the gym. It's also 25 bucks for the year which is so affordable a resident can pay for it.

I have found EMRAP's content to be really poor, and honestly, not sure why so many people hype up this podcast that much. I find the delivery, the jokes, and the overall appeal of it to be super tacky. Maybe it works for some, but not my style.

I'll listen to EmCrit every so often if I want to get into something really new/interesting, but I don't really stay on top of it regularly.

 

[gro2001]

Question for the attendings out there. What do you guys do to keep current and/or knock out your CMEs? EBMedicine, EMReports, Critical Decisions, EMEDHome, EMRAP, EMCRIT? Seems there is a plethora of possibilities as an attending, but its all way more friggin expensive now than being a resident/fellow. Trying to do what I can do stay on top of my **** and not spend an arm and a leg.

Any thoughts appreciated.

In terms of CME I meet most of my requirements through a combination of:
1) Conference attendance (most will get you about 20 hours of CME)
2) Up To Date (if you are logged in whenever you do a search it gives you like 0.5 CME for reading the article; that adds up quick)

In terms of staying updated:
1) Textbook: I pick up a textbook occasionally and work my way through it over months. These days I read more ICU texts. ICU book by Paul Maurino, the NeuroICU book, etc.
2) Podcasts: I listen to EM:RAP on the way to work. Occasionally EM:Crit, though the utility for that has dropped off for me a couple of years ago. There seems to be less and less actual hardcore
3) Journal reading: I have a few journal in rotation where I skim their outlines each month and read the articles that catch my interest throughout the month.

 

[deuist]

EMA comes as a part of the EMRap subscription and is so much more relevant compared to most of the EMRap content. UpToDate is good to look stuff up at work, but I don't use it at home. I try to go to a conference every couple of years. They're useful for catching up with people I went to residency with. You can try to read through journals, but now most of them have free podcasts.

 

[Brigade4Radiant]

Emrap is pretty good as well as going to EM message boards. I never use text books as I find them a waste of time.

Podcasts and discussion based learning is where I feel you learn the most as well as questions. Text books are good for an initial base knowledge and drop off after that.

Text books are often outdated as well think about how much knowledge we gain just by casual use on this board.

 

[Birdstrike]

Things that I've heard old men say at my one job site:

"You can't have a kidney stone if there's no blood in the urine."
"Reflexes are like a poor man's MRI. If they're normal, there's nothing wrong."
"Clindamycin kills Merserrr (MRSA)?"
"If the HCG is below 2000 they're not pregnant."

HOLY MOLY.

What is up with the reflexes comment? Where does that even come from? You can have a major stroke and reflexes are normal. LOL

I haven't worked a general EM shift in years (although the neuro stuff, I see daily). For fun, I'm going to fact check these. Then you grade me. Ready, set, go...

As to the kidney stone and HCG comments, yeah...wrong. Not ruled out if neg heme or hcg <2000. Work it up. I could go a hundred years without working in an ED an not forget that. Patently false.

As far as reflexes go, I'll rate that one "mostly false." Of course, it depends on which reflexes you're talking about, but commonly tested extremity reflexes (patellar, achilles, triceps, biceps) have nothing to do with acute cva, as they go through the spinal cord and bypass the brain. So, yeah, that's a weird comment. Unless they're referring to acute spinal cord catastrophes(?) there's more utility. In general, there are very few exam findings that are so sensitive that they have a negative predictive value good enough to supplant modern imaging and testing. So yeah, don't skip the CT and neuro workup "cuz reflexes." Lol

As far as the clindamycin thing goes, I'll give that a "partly false." What kills MRSA (or any other bacteria) is always a moving target. It all depends on the susceptibility in your area based on cultures. But yes, clindamycin (some) can cause inducible resistance in MRSA, and you need a d-test to confirm if it's a therapeutic option. But that attending is partly correct in that sometimes clindamycin kills MRSA. That number may not be anywhere near 100%. But when people make blanket statements such as "____" antibiotic kills "____" organism, you're really only talking in percent likelihoods. A given antibiotic may kill a certain percentage of isolates of a certain strain of bacteria. When the number is 99% or closer to the 0% end of the spectrum, it's easy to talk and feel certain. But look at your local micro labs nomograms. You may see numbers like 75%, 85% or 90% for antibiotics that's you've been told were certain to kill a given organism. In other words, you may even be wrong 10, 15 or 25% of the time, even when you're "right" on a given bacterial strain. And your dinosaur attending might be right a certain percentage of the time (if d-test, not resistant, culture, etc) like a broken clock is also right, twice per day. Lol

We like to make things bullet-point simple in EM. Often they're not. But they're always Lol.

 

[thegenius]

As far as the clindamycin thing goes, I'll give that a "partly false." ...(sip)

Clindamycin is still an acceptable Abx for MRSA, despite its inadequacies, according to the IDSA. I dunno if it kills Meerrrrsa though.

 

[Birdstrike]

Clindamycin is still an acceptable Abx for MRSA, despite its inadequacies, according to the IDSA. I dunno if it kills Meerrrrsa though.

What about "spieyeeder" bites?

 

[Paperman]

Things that I've heard old men say at my one job site:

"You can't have a kidney stone if there's no blood in the urine."
"Reflexes are like a poor man's MRI. If they're normal, there's nothing wrong."
"Clindamycin kills Merserrr (MRSA)?"
"If the HCG is below 2000 they're not pregnant."

NEVER in my life heard #1,2 & 4. But RF works in FLA so that could explain a lot.....

 

[RustedFox]

NEVER in my life heard #1,2 & 4. But RF works in FLA so that could explain a lot.....

All spoken by grey old men who very clearly "phone it in" while on-shift.