Learn more first year out than residency?

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Gither

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Want to get your input. Always heard people say, “you’ll learn more your first year out (attending) than all 3/4 years in residency.” I know this phrase isn’t to be taken literally but is this concept true? I’m 9 months into being an attending at a pretty high acuity community ED and we are drowning and redlining the entire shift. There’s a decent amount of turnover and the other more senior attendings have told me the pace is difficult to sustain long term and many are burning out. Staffing/system issues, etc like many EDs out there. I plan on staying long term just for the experience and hoping the phrase above is true. Trying to have a positive attitude about it. Ive convinced myself that if I can survive here, I can work anywhere and be competent.

On the other hand, also heard most new grads find a new job after a couple years. Considered leaving as this career is a marathon and burn out is real. However, if the quote above is true, I’d stay for a while and treat this like “attending residency” training if that even makes sense.
 
OP, did you attend a four or three year residency?
 
No, I learned the majority of what I needed to learn in residency. Once outside of residency took me a little time to get used to not being a resident anymore and had to increase my throughput (not horribly difficult since I no longer had to take the step of presenting patients). That said, if you are drowning the entire shift and have that affecting you, you either need a new job or an outlook adjustment, or are in an area that has a seasonal population (e.g., Florida, and it will get better in April or May). Don’t be scared to change jobs if the one you’re at isn’t right for you. What’s the patients per hour?
 
As a newer attending, I actually think daily about how much I learned in residency, and how well my residency actually prepared me to be an attending. I’ve realized that I didn’t appreciate how good my education was while I was in residency, but, now, being an attending and looking back, I can see it.

I too work at a busy hospital with an admission rate that’s near double the national average. High acuity. Sick patient population. 100mph most shifts the entire time. When I was in med school and residency, I never heard one of my EM mentors say that they wished they worked more when they were early in their careers. Every single one of them wished they had worked less, so I’ve kept that in mind. I only work 100-115 hours a month, 12-14 shifts, trying to get closer to 12. I don’t live a fancy lifestyle. Don’t drive a Mercedes and don’t live in a million dollar house, so I don’t need to work 18-20 shifts a month. I’m pretty happy right now. Work no more than 3-4 shifts in a row. Always have a block or two of 5-8 days off with a smattering if 2 or 3 day blocks as well. The good thing about EM is that you can work 3 days a week and still pull $300k+ per year, have a comfortable lifestyle, and have plenty of family time as well. Balance is the key. Life isn’t all about work. If you are starting to feel that way now, try cutting back a little and see what happens.
 
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Assuming you did no moonlighting during residency, I think this is more about learning more about yourself as a physician and your abilities/limitations and how to manage a department more so than pure medical knowledge (because that makes zero sense). I moonlighted for over 1,000 hours in residency so I didn’t notice much of a difference. That first moonlighting shift though, oh man, scary af. I think that’s where the saying comes from, flying solo.
 
Tenk said:
I think this is more about learning more about yourself as a physician and your abilities/limitations and how to manage a department more so than pure medical knowledge (because that makes zero sense).
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This is what I was trying to figure out. Heard the saying “you’ll learn more your first year out...” so many times I just wanted to get a sense of what it actually meant.

Don’t think I was clear with my first post. Residency training was great. I actually feel like I was just as busy during a shift in residency as I am now. I don’t work nearly as many hours and love how many days off I have. Just wanted to see if the benefits outweighed the risk of early burn out if I were to stay with a job that is this brutal (during the shift) the first few years out compared to another department that isn’t going “100mph” as described by another poster above.
 
Apollyon said:
I did more Ortho my first year out, and I plainly blame my residency.

However, I am now 13 years out, and I am just generally weak.
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You know, funny thing is I thought my residency training was weak on ortho and ophtho. However, now that I am a couple of years out and have had a chance to work with folks who've trained all over (and I mean ALL over: different places in the US, UK, Australia, New Zealand, etc) I realize that everybody sucks at ortho and ophtho. Although they were weaknesses for me, it turned out that I wasn't any worse off than anybody else as far as I can tell.
 
Gither said:
Want to get your input. Always heard people say, “you’ll learn more your first year out (attending) than all 3/4 years in residency.” I know this phrase isn’t to be taken literally but is this concept true? I’m 9 months into being an attending at a pretty high acuity community ED and we are drowning and redlining the entire shift. There’s a decent amount of turnover and the other more senior attendings have told me the pace is difficult to sustain long term and many are burning out. Staffing/system issues, etc like many EDs out there. I plan on staying long term just for the experience and hoping the phrase above is true. Trying to have a positive attitude about it. Ive convinced myself that if I can survive here, I can work anywhere and be competent.

On the other hand, also heard most new grads find a new job after a couple years. Considered leaving as this career is a marathon and burn out is real. However, if the quote above is true, I’d stay for a while and treat this like “attending residency” training if that even makes sense.
Click to expand...
I found the above quote to be very true, twice. The first was the first year after EM residency. The second time was my first year doing interventional pain after fellowship. No matter how long you stay in training, there's something that changes when you're on your own, and things you just won't learn until you are. It's those first 6 mos to 2 years that you're solidifying your practice patterns and mental approaches to problem solving and patient care. No extended amount of training allows one to skip this step. Whether or not you stay at your current @Gither, is a whole different matter.
 
I think the answer to this question is based entirely on perspective. Do you learn more the first year out about physiology, medications, procedures, etc? No, of course not. That would be absurd. But do you learn more about the management of an emergency department as an attending? Definitely. Especially if you have are single coverage. You really can’t learn the fine details of single coverage practice as a resident - you learn it when you do it.
 
gro2001 said:
You know, funny thing is I thought my residency training was weak on ortho and ophtho. However, now that I am a couple of years out and have had a chance to work with folks who've trained all over (and I mean ALL over: different places in the US, UK, Australia, New Zealand, etc) I realize that everybody sucks at ortho and ophtho. Although they were weaknesses for me, it turned out that I wasn't any worse off than anybody else as far as I can tell.
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I think ortho is honestly just more challenging than people give it credit. I think there is a stereotype of the dumb orthopedist that contributes. The procedures can be technically challenging and require a lot of practice. I think most academic ER residencies that have a concomitant ortho residency do not give ER residents enough ortho procedures in the ER.
 
RoyBasch said:
I think ortho is honestly just more challenging than people give it credit. I think there is a stereotype of the dumb orthopedist that contributes. The procedures can be technically challenging and require a lot of practice. I think most academic ER residencies that have a concomitant ortho residency do not give ER residents enough ortho procedures in the ER.
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Really? I’m at an ivory tower but did and still do moonlight a lot. I mean, you pull or push real hard, throw on some ortho glass and have them see ortho the next day. How hard is that? Reductions don’t have to be perfect.
 
Gither said:
Want to get your input. Always heard people say, “you’ll learn more your first year out (attending) than all 3/4 years in residency.” I know this phrase isn’t to be taken literally but is this concept true? I’m 9 months into being an attending at a pretty high acuity community ED and we are drowning and redlining the entire shift. There’s a decent amount of turnover and the other more senior attendings have told me the pace is difficult to sustain long term and many are burning out. Staffing/system issues, etc like many EDs out there. I plan on staying long term just for the experience and hoping the phrase above is true. Trying to have a positive attitude about it. Ive convinced myself that if I can survive here, I can work anywhere and be competent.

On the other hand, also heard most new grads find a new job after a couple years. Considered leaving as this career is a marathon and burn out is real. However, if the quote above is true, I’d stay for a while and treat this like “attending residency” training if that even makes sense.
Click to expand...
 
Just reading the OP, but why the "burn out". What are the staffing/system or process issues?
 
TimesNewRoman said:
Really? I’m at an ivory tower but did and still do moonlight a lot. I mean, you pull or push real hard, throw on some ortho glass and have them see ortho the next day. How hard is that? Reductions don’t have to be perfect.
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There are complications to sub-optimal reductions, they are not necessarily catastrophic and you probably never hear about them. That being said, there are some patients who could possibly be treated conservatively with a better reduction that now require surgery because of inadequate reduction, some need a repeat reduction by the orthopedist, some patients need to delay their surgery because of worse soft tissue swelling due to inadequate alignment, some patients now require multiple surgeries such as an initial damage control ex-fix to save soft tissue with subsequent open reduction and internal fixation later, the list of morbidity to varying degrees goes on. As I stated, orthopedics is more difficult than it appears and can be very nuanced.

I don't claim to know everything about orthopedics, but I accept that there is a fair amount of it beyond my ken. Again I am not accusing anybody of substandard care because gross anatomic reduction and splinting satisfies the stabilization of the emergency and the patient is at the point of disposition. However, if you want to achieve the best outcomes on every patient with minimization of any potential morbidity it requires significant skill and experience; which is why some ER physicians perceive orthopedics to be "hard."
 
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TimesNewRoman said:
Really? I’m at an ivory tower but did and still do moonlight a lot. I mean, you pull or push real hard, throw on some ortho glass and have them see ortho the next day. How hard is that? Reductions don’t have to be perfect.
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Yeah. Don't be that guy.
Failure to reduce is an EMTALA violation. All it takes is pissing off one orthopod. Or converting a fracture to open because you didn't pad well enough. This is no different than saying we don't really need to know EKGs, because we have cardiology.
 
Gither said:
Want to get your input. Always heard people say, “you’ll learn more your first year out (attending) than all 3/4 years in residency.” I know this phrase isn’t to be taken literally but is this concept true? I’m 9 months into being an attending at a pretty high acuity community ED and we are drowning and redlining the entire shift. There’s a decent amount of turnover and the other more senior attendings have told me the pace is difficult to sustain long term and many are burning out. Staffing/system issues, etc like many EDs out there. I plan on staying long term just for the experience and hoping the phrase above is true. Trying to have a positive attitude about it. Ive convinced myself that if I can survive here, I can work anywhere and be competent.

On the other hand, also heard most new grads find a new job after a couple years. Considered leaving as this career is a marathon and burn out is real. However, if the quote above is true, I’d stay for a while and treat this like “attending residency” training if that even makes sense.
Click to expand...

I'm trying to follow you but am not 100% sure about what you're asking...

There's nothing magical about a brutal EM gig where you are wiping sweat from your gluteal cleft at the end of every shift. That in no way translates to a "good post residency experience". Nor does the fact that you're fresh out of residency mean that every shift should be grueling. Yes, the first 1-2 years are a lot of learning but it's more in learning how the system works, billing/coding proficiency, time management, furthering skill proficiency, etc.. You can learn those things at just about any job so I don't think that's reason enough to stay where you are if you are currently miserable. A few more specifics might help us give you better advice.
 
Dr.McNinja said:
Yeah. Don't be that guy.
Failure to reduce is an EMTALA violation. All it takes is pissing off one orthopod. Or converting a fracture to open because you didn't pad well enough. This is no different than saying we don't really need to know EKGs, because we have cardiology.
Click to expand...

I’m not saying that we don’t need to be able to do it well, I’m just saying most reductions aren’t difficult. Hips and shoulders go back in and the most common fracture I reduce is distal forearm which usually goes fine. And reductions don’t need to be perfect, they need to be reasonable. I feel like I probably got very average ortho training in residency, but I’m comfortable reducing joint and fractures when I’m in the community. There are a lot of things that make me more nervous than ortho stuff.
 
Groove said:
Speaking of colles fractures, does anyone else do bier blocks? I think I'm the only one in our group that does them... I'm not sure why.
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My guess is you're the only one. I've never seen or even heard of an EP doing this. How do you get the special tourniquet?

As to why others don't do them...local anesthetic toxicity, complicated setup, procedural sedation is faster and safer, not in our scope of practice, etc...
 
Groove said:
Speaking of colles fractures, does anyone else do bier blocks? I think I'm the only one in our group that does them... I'm not sure why.
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Narcotics, finger traps, and hematoma block. Rarely procedural sedation (unless it's a kid).
 
turkeyjerky said:
My guess is you're the only one. I've never seen or even heard of an EP doing this. How do you get the special tourniquet?

As to why others don't do them...local anesthetic toxicity, complicated setup, procedural sedation is faster and safer, not in our scope of practice, etc...
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Easy procedure. I can't even remember when I learned them...sometime during residency. I've been using them for at least 90% of my colles fractures over the years. No need for procedural sedation and beyond excellent analgesia. You can unbelievably crank on these fractures to get a good reduction and the pt is completely pain free. Sometimes I'll add a hematoma block but most of the time I don't. I've done countless and never had a major complication.

Some hospitals will have a bier block pneumatic tourniquet set up that you can use. It's set up specifically for bier blocks. My last hospital had one of these. I was spoiled in that we also had a c-arm in the ED so I could put on a lead apron and manipulate the fracture until it was nicely aligned. My current gig only has a stryker OR pneumatic tourniquet which is basically the same thing. It's pre-set at 250-300 and comes with single or double bladder tourniquets. I use the double bladder. It's incredible easy to use. You power it on and push a single button for each pump and it auto inflates the tourniquet to the pre-set pressure. I used to use ace wrap to milk the blood out of the extremity but I don't anymore because anecdotally I don't really notice any enhancement of analgesia and it just takes longer. For a 70kg person I usually use 40cc of 0.5% lidocaine. I have gone back and forth over the years between 20cc 1% or 40cc 0.5% and I seem to notice slightly better effect with the larger volume.

You put them on the monitor, put an IV in their contralateral arm in case you need it for any complications and pop in a second IV, preferably in the hand, of their affected arm. Blow up the cuff, push the lidocaine, pull the IV out and put on a bandaid. The arm will get all mottled and after a few minutes they can't feel anything. It's wonderful analgesia for the pt and they are wide awake. I do the reduction, splint, leave the cuff up for 20 mins and deflate. Easy. I've done countless and they are all very smooth. The one complication was when a nurse inadvertently let the cuff down too soon and the pt became a little dyspneic and tachycardia from the sudden rush of lidocaine but it was transient and they did just fine. You just have to stress to the nurses and pt not to touch the cuff. I also warn the pt before we start that the cuff will begin to hurt pretty bad around the 20 min marker but virtually everyone can tolerate it just fine. These really don't take that long and are certainly much faster than any procedural sedation that I could do. (Less paperwork too.)
 
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These pneumatic tourniquets are also very handy when you have bad extremity lacs and need a bloodless field, especially when you have arterial bleeders. Most ORs should have one. It's a lot easier than having your scribe sit there getting hand cramps from pumping up the manual cuff while you sew a complex lac.
 
Groove said:
Easy procedure. I can't even remember when I learned them...sometime during residency. I've been using them for at least 90% of my colles fractures over the years. No need for procedural sedation and beyond excellent analgesia. You can unbelievably crank on these fractures to get a good reduction and the pt is completely pain free. Sometimes I'll add a hematoma block but most of the time I don't. I've done countless and never had a major complication.

Some hospitals will have a bier block pneumatic tourniquet set up that you can use. It's set up specifically for bier blocks. My last hospital had one of these. I was spoiled in that we also had a c-arm in the ED so I could put on a lead apron and manipulate the fracture until it was nicely aligned. My current gig only has a stryker OR pneumatic tourniquet which is basically the same thing. It's pre-set at 250-300 and comes with single or double bladder tourniquets. I use the double bladder. It's incredible easy to use. You power it on and push a single button for each pump and it auto inflates the tourniquet to the pre-set pressure. I used to use ace wrap to milk the blood out of the extremity but I don't anymore because anecdotally I don't really notice any enhancement of analgesia and it just takes longer. For a 70kg person I usually use 40cc of 0.5% lidocaine. I have gone back and forth over the years between 20cc 1% or 40cc 0.5% and I seem to notice slightly better effect with the larger volume.

You put them on the monitor, put an IV in their contralateral arm in case you need it for any complications and pop in a second IV, preferably in the hand, of their affected arm. Blow up the cuff, push the lidocaine, pull the IV out and put on a bandaid. The arm will get all mottled and after a few minutes they can't feel anything. It's wonderful analgesia for the pt and they are wide awake. I do the reduction, splint, leave the cuff up for 20 mins and deflate. Easy. I've done countless and they are all very smooth. The one complication was when a nurse inadvertently let the cuff down too soon and the pt became a little dyspneic and tachycardia from the sudden rush of lidocaine but it was transient and they did just fine. You just have to stress to the nurses and pt not to touch the cuff. I also warn the pt before we start that the cuff will begin to hurt pretty bad around the 20 min marker but virtually everyone can tolerate it just fine. These really don't take that long and are certainly much faster than any procedural sedation that I could do. (Less paperwork too.)
Click to expand...

While this sounds interesting, I second the comments above about hematoma blocks. The last 4 or 5 distal radius fxs I've had I simply did a hematoma block and then pulled on it. Nothing else needed.
 
BoardingDoc said:
While this sounds interesting, I second the comments above about hematoma blocks. The last 4 or 5 distal radius fxs I've had I simply did a hematoma block and then pulled on it. Nothing else needed.
Click to expand...

Diff strokes, diff folks. Whatever works. I find that I get better reductions this way and the pts are much more comfortable but like most things in our specialty..there’s no single way to do things. Try it out sometime. They aren’t difficult.
 
Groove said:
Diff strokes, diff folks. Whatever works. I find that I get better reductions this way and the pts are much more comfortable but like most things in our specialty..there’s no single way to do things. Try it out sometime. They aren’t difficult.
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Honestly, I'm really intrigued with it. I too have less than ideal results with hematoma blocks, so I usually go for sedation if I need a good reduction. You should write up an article for EM News about it--I'm sure this is a novel approach most of us.
 
The only people I've heard of doing them are a few old guard EM docs who've been practicing for over 30 years.

Mostly do axillary blocks nowadays which seem to work better than hematoma blocks for most patients.
 
But yeah seems way easier than I thought and might have to try it out next time.
 
At the county hospital where I was a medical student we did Bier blocks for fracture reductions. Seemed effective. That being said, I haven't done one since and I have never done one as a staff physician. Seems like a good technique but I suspect it is not commonly practiced in the ER on account of lack of familiarity rather than risk or complications.
 
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