I would caution individuals to make blanket statements about types of programs without looking into the nuance of each program.
Thank you for your very insightful and, and IMO, very accurate post. One of my biggest frustrations, however, on SDN and amongst MS4s on the interview trail, is the notion that county programs are ALL about doing ED thoracotomies and and crichs ALL day EVERY day (note the extremes of language that I intentionally used). It's like somewhere, somehow, probably due to Code Black or some other form of media, there has been this notion that the badass county ED resident with his mismatched scrub top and cargo pants, patagonia vest and crocs is just saving lives 24/7 in epic fashion. That, to me, is a gross misrepresentation of what occurs at county facilities. Yes, they see high acuity patients. But, as a safety net hospital, they see low acuity patients as well. Overall they provide very well balanced training. This idea that there are no academic opportunities at county hospitals is ludicrous since the bastion of EM medical education was born at LAC+USC (EM:RAP), the editors of Rosens are at Harbor, and some of the most influential research in prehospital care is coming out of Hennepin.
When you look at many of the most coveted spots in EM residencies, many of them are at county programs. If you care about a well balanced education, have a desire to serve the underserved etc, these are great places to train. But, I personally believe that some people choose county programs for the misinformed "sex" appeal of working there. Having rotated at a few county hospitals in medical school, I remember pushing patients to CT scanners. I remember many of the residents being overworked, and taking care of your typical non-english speaking patient with "total body dolor" that ultimately revealed NO emergent cause of illness that should have been worked up by a PMD (which they did not have access to). These aspects of the county experience are simply not part of the narrative and not openly shared when discussing these programs.
Do academic programs have low acuity as well? Absolutely. As a resident at an academic hospital I am constantly barraged by patients with "expensive" health insurance who show up to the ED with a stubbed toe and request that their "personal doctor" be notified immediately and see them in the ED right this instant. It's true, I see the bowel transplant patient who I literally just pick up a phone and call the consultant and write a note. But I also see a ton of high acuity penetrating trauma, do a lot of awake fiberoptic intubations without anesthesia/ENT backup, and have already done 2 perimortem c-sections in residency (granted with OB backup).
The idea that county programs are all high acuity and no primary care is false. The idea that all academic programs are all consult calling without any ownership of patients is false. There are academic programs in this country that see more penetrating trauma than some county programs. There are county programs that put out more research and more influential publications than some academic programs.
In other words, I agree you with you completely, just was chiming in and giving my thoughts on the subject.
But while there is no doubt on SDN in particular that county programs all give great training (a statement I would agree with), I think academic programs here do get shafted and are often misrepresented more so than county programs for being full of just a bunch of nerds who wear their white coats on shift and never know how to resuscitate a patient without calling a consult first. I remember rotating at a county hospital and one resident in particular (a particular bad egg, not a reflection of all county residents) said "academic training is subpar, in county medicine we own our patients and actually deliver emergency care instead of just calling consults 24/7 and having others do the life saving procedures". I remember being really turned off by that comment, as what you alluded to in your post, it was nothing more than a sweeping generalization. Regardless, that "mindset" towards academic programs does persist in some aspects of our specialty and frankly I think it's unwarranted.
