Learning to Run the ED.....help!

[WolfMD]

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Sooo....I just started residency at a 3 yr university based program with a very decent reputation in the EM community. That being said, my home program was a 4 yr county program where the residents learned to RUN the department. The 4th yr residents were very impressive in their ability to manage the dept (EMS, lower level residents etc etc..plus all the pts). Downsides to that program were that the attendings never taught, were frequently not even visible, and the didactics sucked.

My situation is this: attendings are awesome, always teaching. Didactics are great. The dept is full of sick pts. I have no doubt that I will learn to be a great doctor here and manage pts. BUT.....the 3rd year residents are doing 1-on-1 patient care, not running the show. My question to those who may have graduated from a program like mine is this: when will I learn to run the ED? Am I going to have to do a fellowship in administration? One of the reasons I went into EM was for the administrative aspect of it, and my top choice programs were programs where I would have learned that stuff....but alas.

I really like my program and I am going to make the best of it -- just want some advice from those who may have been practicing for awhile re. how this experience is gained if not in residency.

Thanks!!!!

 

[Hamhock]

I am a resident at a 4y county program, so I may not be who you want to hear from...

However, I will say that many of my training concerns when I was an intern have been solved or disappeared without any extra effort on my part.

I would recommend not worrying about "running the ED" as a senior resident now, when you are a brand-new intern. Concentrate on intern stuff and worry about this later.

Just my very humble opinion, though.

HH

 

[WilcoWorld]

I agree with the above that "running the room" needn't be your big concern for now. Additionally:

1- Being able to perform the "1 on 1" patient care is the most important thing for you to learn from residency. If you can't care for a patient you can't run a whole ED full of 'em!

2- I went to a 3 year program. By year 3 my attendings were more than happy to sit back and let me run the room when I took the initiative. If you're up to speed on #1 by year 3, I suspect your attendings will feel the same way.

 

[deleted65604]

Academic attendings run the department, out of necessity, by pawning off work on other people. Their residents do the vast majority of pelvics, rectals, lac repairs, splinting, LPs, I&D's, etc.

Residents also do the lion's share of documentation such as full H&Ps, social history, discharge instructions, all the crossed t's and dotted i's that are important for billing purposes, and not for true patient care.

For the difficult dispositions, they just force some intern on another service to come down and make the disposition.

Easiest patient in an academic ER? A sick trauma patient. The surgery team is there, ER residents grab any procedures they can and then quickly disappear the minute it gets boring while the surgery residents are dictating their notes and either taking the patient to surgery or admitting them. Stroke symptoms? Order CT, stroke protocol order-set, activate stroke team and walk slowly away...dispo per neuro. STEMI? Call cath lab, give aspirin, nitro, and maybe start some heparin if the cardiologist isn't at the bedside yet.

Pawning off work is something that I'm sure will come naturally to you if you work at an academic institution. If you work without residents, you need to learn to dispo one patient at a time as rapidly as possible, and that is going to come with just diving in and seeing as many patients as you can.

I might argue that if you are not planning on working in an academic center, that you need to be involved extensively in the decision-making alongside your consultants to help you make your own patient dispositions in the future. I think emulating your attending's behavior as a resident could be detrimental to your training.

 

[SoCuteMD]

Sooo....I just started residency at a 3 yr university based program with a very decent reputation in the EM community. That being said, my home program was a 4 yr county program where the residents learned to RUN the department. The 4th yr residents were very impressive in their ability to manage the dept (EMS, lower level residents etc etc..plus all the pts). Downsides to that program were that the attendings never taught, were frequently not even visible, and the didactics sucked.

My situation is this: attendings are awesome, always teaching. Didactics are great. The dept is full of sick pts. I have no doubt that I will learn to be a great doctor here and manage pts. BUT.....the 3rd year residents are doing 1-on-1 patient care, not running the show. My question to those who may have graduated from a program like mine is this: when will I learn to run the ED? Am I going to have to do a fellowship in administration? One of the reasons I went into EM was for the administrative aspect of it, and my top choice programs were programs where I would have learned that stuff....but alas.

I really like my program and I am going to make the best of it -- just want some advice from those who may have been practicing for awhile re. how this experience is gained if not in residency.

Thanks!!!!

There are very few 3 year programs where you will learn to "run the department" - as there simply isn't time to learn all the medicine you need to AND take on a serious supervisory role in 3 years. But, as many on this board will point out, the EDs in this country are primarily staffed by 3 year grads and they seem to do just fine.

 

[KYTNOH]

If you look at the 4 year programs in the country and compare them to the 3 year programs the total time in the ED will be fairly similar. When i interviewed the 4 year programs give you more time out of the ED your first couple of years and then seem to have more elective time in the 3rd and 4th years. ED time may only be two or three months less in a three year program when compared to a four year program, so your performance in the ED probably won't be that different.

 

[SoCuteMD]

If you look at the 4 year programs in the country and compare them to the 3 year programs the total time in the ED will be fairly similar. When i interviewed the 4 year programs give you more time out of the ED your first couple of years and then seem to have more elective time in the 3rd and 4th years. ED time may only be two or three months less in a three year program when compared to a four year program, so your performance in the ED probably won't be that different.

I only know what I've seen - which is that 4 year programs tend to have an integrated supervisory role and that is much less common in 3 year programs.

I'm staying far away from the 4 year vs. 3 year debate.

 

[BADMD]

BUT.....the 3rd year residents are doing 1-on-1 patient care, not running the show. My question to those who may have graduated from a program like mine is this: when will I learn to run the ED? Am I going to have to do a fellowship in administration?

What do you mean "run the ED?" Do mean supervise residents and medical students practicing medicine or do you mean manage the administrative nuts and bolts?

If the former, then the best way is to learn to manage flow. Most EPs are not supervising residents or medical students. Most are out there seeing patients and providing one on one patient care. Learning to manage the flow of the ED is the way you learn to run the department, on a day to day basis. Your 3rd years were 2nd years less than a month ago, and I suspect the attendings are still keeping the leash a little tight.

If the latter, then I doubt most, if any, programs will give you enough administrative experience to run an ED effectively. Most EPs that I know who have gotten themselves there, acquired their position by first volunteering to tackle projects and took opportunities to supportive the administrative functions of the ED. As they took larger and larger roles, they moved into positions as they became available. An administrative fellowship will certainly help and will often allow you jump certain initial roadblocks. Many will give you credentials (ie, MBA) that others won't have.