Longtime SDN member and current EM resident - AMA or don’t. Whatever.

[ZorkDork1]

The ER is divided into 6 modules and each one has 2 residents plus an attending. After patients are triaged they are assigned to one of the modules based on their order of arrival (mod 1 gets the 1st, mod 2 gets the 2nd, mod 3 gets the third). That way no one gets slammed if 10 seriously injured patients walk through the door at the same time.

So does module 1 always get first pick, in the event that 10 seriously injured patients don't come in at the same time?

In other words, if one patient arrives every 1.5 hours, does the patient always go to Module 1 first, or is it more like module 1, and then module 2, and then module 3?

Thanks!

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[ZorkDork1]

Also, what's your strategy to dealing with flip flopping your sleep schedule to accommodate day/night shifts?

 

[Vladimir7]

Hey, idk if you've answered this already, or if its too convoluted of a question: But what are your thoughts on Healthcare in America. As a doctor, do you think we should have a single payer system, keep the current system, or drop all government involvement in healthcare altogether (medi-cal, obamacare). If there's a link to an article or what someone says that fits perfectly what your thoughts are, that works too.

What I've seen is this, America can provide some of the best care in the world, but that comes at a price, a big one. What would be the best step to ensure better priced healthcare, but without diminishing the overall quality by too much.

 

[alpinism]

So does module 1 always get first pick, in the event that 10 seriously injured patients don't come in at the same time?

In other words, if one patient arrives every 1.5 hours, does the patient always go to Module 1 first, or is it more like module 1, and then module 2, and then module 3?

Thanks!

So no one really gets to pick their patients. The triage nurse just assigns them to the modules.

For example if there's a multi car MVA on the interstate with 3 patients:

Whichever module is next up gets the 1st patient, then the next module gets the 2nd patient, and the next module gets the 3rd patient. If module 1 had the last patient then module 2 would get patient 1, module 3 would get patient 2, and module 4 would get patient 3. If module 2 had the last patient then module 3 would get patient 1, module 4 would get patient 2, and module 5 would get patient 3. As a result most shifts patients are shared equally between all the modules.

In reality its a little more complicated than that since one of the modules is a prisoner module for county jail patients and they don't see regular patients. In any event hopefully you get the general idea of how our ER functions with regards to patient flow and assigning patients to different modules.

 

[alpinism]

Also, what's your strategy to dealing with flip flopping your sleep schedule to accommodate day/night shifts?

I usually stay up after my last night shift if I'm switching to days. Sucks for a few hours during the afternoon but I usually end up well rested the next morning.

 

[Shmoclo]

What us the best EM residency in the NY area a DO with good boards, research, LORs can get into?

 

[Gurby]

Has your view of EMS and EMS providers changed at all, now that you're on the other side? Is there anything about EMS you would like to change, that you didn't realize was a problem before?

As a medic, I always love when the doc comes in right away after we drop a patient off. I like watching them do their assessment and when they're willing to teach or grill/(pimp?) me about things. If I go into EM, I hope to be that doc who makes the effort to be more involved with EMS. Will I have this optimism beaten out of me by the realities of working in such a fast paced environment?

 

[alpinism]

Hey, idk if you've answered this already, or if its too convoluted of a question: But what are your thoughts on Healthcare in America. As a doctor, do you think we should have a single payer system, keep the current system, or drop all government involvement in healthcare altogether (medi-cal, obamacare). If there's a link to an article or what someone says that fits perfectly what your thoughts are, that works too.

What I've seen is this, America can provide some of the best care in the world, but that comes at a price, a big one. What would be the best step to ensure better priced healthcare, but without diminishing the overall quality by too much.

My thoughts:

I think the US has a horrible healthcare system. I grew up overseas in England so I'm probably biased but I highly prefer the NHS system. The article below basically sums up my own experiences and opinion on the subject. The sections on emergency medicine are especially relevant. In any event, I always laugh when someone says that America has the best healthcare system in the world. I'd personally much rather work in an UK NHS hospital than in a US private hospital.

An American Uses Britain's NHS - Business Insider

 

[alpinism]

What us the best EM residency in the NY area a DO with good boards, research, LORs can get into?

AFAIK all the NYC EM residencies except NYU take DOs.

 

[Psai]

AFAIK all the NYC EM residencies except NYU take DOs.

http://www.med.nyu.edu/emergency/our-people/our-residents-2016-17

I can see why lol

 

[alpinism]

Has your view of EMS and EMS providers changed at all, now that you're on the other side? Is there anything about EMS you would like to change, that you didn't realize was a problem before?

As a medic, I always love when the doc comes in right away after we drop a patient off. I like watching them do their assessment and when they're willing to teach or grill/(pimp?) me about things. If I go into EM, I hope to be that doc who makes the effort to be more involved with EMS. Will I have this optimism beaten out of me by the realities of working in such a fast paced environment?

Good Question.

The further along I get in training the more I realize how important good BLS care is for emergency patients (compressions/defibrillation/ventilation/naloxone/dextrose/etc...). Unfortunately, at the same time, the further along I get in training the more I also realize that ALS care seems to provide little to no benefit for most patients. There seems to be this biphasic curve in emergency medical care whereby most lifesaving interventions either fall into the category of very basic or very advanced. Trauma care is a great example. Most initial care can easily be performed by an EMT-B (hemorrhage control and splinting) while most continuing care needs physician level training (injury assessment and performing invasive procedures). The interesting thing is that when medics were first created most basically functioned as EMT-Bs with IV training (current AEMTs). The whole EMT-Ps doing intubations and giving medications concept is a fairly recent phenomenon and has never really had any evidence of improved outcomes. As a result the best EMS set up at the moment seems to be AEMTs with EM physician back up for seriously injured patients. This is what happens in most Australian and European cities.

Yeah I love doing that too. Unfortunately most of the time I'm too busy talking with other patients, doing procedures, or working on paperwork. However, If the patient is coding or unstable I usually try to meet EMS at the door and keep them around for the initial resuscitation. Of course when that happens I'm always happy to teach and answer any questions.

 

[ZorkDork1]

Say that one is set on pursuing EM.
What are your tips for an incoming MS 1 on landing a solid residency in EM?

Thank you!

 

[alpinism]

http://www.med.nyu.edu/emergency/our-people/our-residents-2016-17

I can see why lol

For some reason NYU refuses to rank DOs.

And its not just EM, every residency there has a huge anti-DO bias.

 

[alpinism]

Say that one is set on pursuing EM.
What are your tips for an incoming MS 1 on landing a solid residency in EM?

Thank you!

1. Pass all your classes
2. Get a good step 1 score
3. Join your school's EMIG
4. Go to national EM conferences
5. Network with residency programs
6. Do 2 away rotations and get strong SLOEs
7. Apply early and broadly to EM programs nationwide.
8. Profit.

 

[pillowsnice]

I am involved with EMS and whenever we get arrests or some life threatening problem, I get this sort of goosebump like feeling. Do you relate lol? I'm thinking this may be a sign I should do EM or I'm just weird.

Also, not sure if you answered this, but how often are you able to follow up on patients after they leave the ED? Something that doesn't happen in EMS is knowing what happens to the patient and I want to know if it's the same as an EM physician.

 

[ZorkDork1]

1. Pass all your classes
2. Get a good step 1 score
3. Join your school's EMIG
4. Go to national EM conferences
5. Network with residency programs
6. Do 2 away rotations and get strong SLOEs
7. Apply early and broadly to EM programs nationwide.
8. Profit.

I noticed you didn't say much about research. Was that on purpose?

 

[alpinism]

I am involved with EMS and whenever we get arrests or some life threatening problem, I get this sort of goosebump like feeling. Do you relate lol? I'm thinking this may be a sign I should do EM or I'm just weird.

Also, not sure if you answered this, but how often are you able to follow up on patients after they leave the ED? Something that doesn't happen in EMS is knowing what happens to the patient and I want to know if it's the same as an EM physician.

Haha. That's probably the adrenaline pumping through your body. Be careful, the feeling is addictive.

It happens, although not that often to be honest. If there's an interesting case or some rare disease you've never seen before you can always look up their chart or visit them upstairs. For most patients though there's really no reason to follow up especially if the case was straight forward and you already made the diagnosis.

 

[alpinism]

I noticed you didn't say much about research. Was that on purpose?

Most EM residencies care very little about research. Yeah it will help your application if you have some, but if not its certainly not a deal breaker.

Obviously there are exceptions to every rule and some residences care about research more than others, but overall its not a requirement like in other fields.

 

[Psai]

I don't know why residencies care so much about research. They're all like "we want to produce leaders in the field" but these guys already working a ton? Why saddle people with nonsense quality improvement projects?

 

[pillowsnice]

Haha. That's probably the adrenaline pumping through your body. Be careful, the feeling is addictive.

It happens, although not that often to be honest. If there's an interesting case or some rare disease you've never seen before you can always look up their chart or visit them upstairs. For most patients though there's really no reason to follow up especially if the case was straight forward and you already made the diagnosis.

Hmm, is that how you got hooked?

 

[alpinism]

Hmm, is that how you got hooked?

Its one of many reasons.

I'm a huge adrenaline junkie who gets bored very easily. EM seemed like the perfect fit when I was applying.

 

[ZorkDork1]

How do older ER docs seem to enjoy their jobs compared to similar aged physicians in different fields?

 

[avgn]

I don't know why residencies care so much about research. They're all like "we want to produce leaders in the field" but these guys already working a ton? Why saddle people with nonsense quality improvement projects?

It brings the bacon home. Every grant needs people to work on them and every grant has an administrative percentage that the school/hospital takes to use for its own purposes. $$$$$$$$$$

 

[alpinism]

How do older ER docs seem to enjoy their jobs compared to similar aged physicians in different fields?

EM has its own fair share of burnt out older docs just like other fields.

That being said, most people hate the current US healthcare system not EM specifically.

Overall though I haven't really noticed a significant difference in job satisfaction compared to other fields.

 

[FutureOncologist]

Without offending all the surgeons on here

Too late.

But for real, what's the dumbest thing your patient(s) have ever told you to get out of legal trouble? Moral destitution? Etc.

 

[jeffk805dent]

Its very easy to find a job in EM these days. You just have to be willing to take a pay cut if you want to live in a more desirable location. I have no idea specifically how easy it is to get a job in other specialties since I'm not in those fields and have never applied for a job as a surgeon or anesthesiologist. That being said as far as I know it does seem to be easier to find an job in EM compared to most other fields.

How much of a paycut do EM's normally take in the bigger cities (NYC, LA, Boston, Las Vegas, Austin, Phoenix, Miami)? Do they also tend to work more hours than EM's in less desirable locations or is it generally the opposite?

 

[avgn]

How much of a paycut do EM's normally take in the bigger cities (NYC, LA, Boston, Las Vegas, Austin, Phoenix, Miami)? Do they also tend to work more hours than EM's in less desirable locations or is it generally the opposite?

Lol @ Vegas, Phoenix, Austin being in that list of

 

[alpinism]

Too late.

But for real, what's the dumbest thing your patient(s) have ever told you to get out of legal trouble? Moral destitution? Etc.

On multiple occasions I've had patients claim its okay to [insert crime here - drive drunk, smoke crack, punch their wife] because "this is America and I can do whatever I want!"
We even had a drunk driver in the trauma bay who wouldn't stop singing the national anthem. Whenever someone told him to stop his response was " f*ck you I love America!"

 

[alpinism]

How much of a paycut do EM's normally take in the bigger cities (NYC, LA, Boston, Las Vegas, Austin, Phoenix, Miami)? Do they also tend to work more hours than EM's in less desirable locations or is it generally the opposite?

Obviously it depends on the specific city but in some places you take a huge paycut (150/hr in metro LA compared to 300/hr in rural Texas). When you also factor in the cost of living and income taxes its even worse (100/hr vs. 300/hr). As a result people in more desirable locations tend to work more hours to pay off loans and maintain the same lifestyle.

 

[alpinism]

Lol @ Vegas, Phoenix, Austin being in that list of

Yeah Las Vegas and Phoenix are actually known for having pretty good pay.

Unfortunately Austin has some of the lowest pay in Texas.

 

[jeffk805dent]

Yeah Las Vegas and Phoenix are actually known for having pretty good pay.

Unfortunately Austin has some of the lowest pay in Texas.

Austin is pretty popular nowadays that it has become congested, I think Dallas is starting to feel the same effects too

 

[Australopithekus]

Its one of many reasons.

I'm a huge adrenaline junkie who gets bored very easily. EM seemed like the perfect fit when I was applying.

And does it still? What else where you considering and why did you pick EM?

 

[The Buff OP]

@alpinism Do you even lift, bro?

 

[alpinism]

And does it still? What else where you considering and why did you pick EM?

EM in the US basically ranges from 90% primary care (large academic hospitals) to 95% primary care (small community hospitals). In an average week you'll treat 10-20 non emergencies for every true emergency. In a typical shift you see mostly non emergent headaches, back pain, abdominal pain, vomiting, dizziness, and weakness. This is in addition to all the frequent flyer nursing home residents, drug seekers, and alcoholics. Its nowhere near as exciting as it is on TV. The only exception would be working in the resuscitation bay at a busy inner city hospital. That's where all the truly sick and dying patients are treated. Unfortunately there's no such thing as a resuscitation residency and you spend most of your time working in the main emergency room.

Now I knew all of this going into EM but its one thing to be told that most of the job sucks and a whole other thing to experience it every day. Part of me was also hoping that there might still be a few ERs out there that only take care of real emergency patients. At least in the US this does not seem to be the case anymore and I don't expect things to change anytime soon. Don't get me wrong though, I still love taking care of those 10% of patients that are truly sick and need to be in the ER, its just that other other 90% can really suck some shifts. The only other specialty I seriously considered was anesthesia but its even more boring than EM 99% of the time. In addition you don't ever get your own patients and you don't ever get to fix anything except when things go horribly wrong in the OR a few times per year.

 

[Tipsy McStagger]

EM in the US basically ranges from 90% primary care (large academic hospitals) to 95% primary care (small community hospitals). In an average week you'll treat 10-20 non emergencies for every true emergency. In a typical shift you see mostly non emergent headaches, back pain, abdominal pain, vomiting, dizziness, and weakness. This is in addition to all the frequent flyer nursing home residents, drug seekers, and alcoholics. Its nowhere near as exciting as it is on TV. The only exception would be working in the resuscitation bay at a busy inner city hospital. That's where all the truly sick and dying patients are treated. Unfortunately there's no such thing as a resuscitation residency and you spend most of your time working in the main emergency room.

Now I knew all of this going into EM but its one thing to be told that most of the job sucks and a whole other thing to experience it every day. Part of me was also hoping that there might still be a few ERs out there that only take care of real emergency patients. At least in the US this does not seem to be the case anymore and I don't expect things to change anytime soon. Don't get me wrong though, I still love taking care of those 10% of patients that are truly sick and need to be in the ER, its just that other other 90% can really suck some shifts. The only other specialty I seriously considered was anesthesia but its even more boring than EM 99% of the time. In addition you don't ever get your own patients and you don't ever get to fix anything except when things go horribly wrong in the OR a few times per year.

I was recently listening to a podcast with Dr. Weingart and Dr. Mallemat where they were discussing critical care fellowships and why you should or should not do them. Scot Weingart made a comment about how he thought EM would soon evolve to where you would either work the EM (low acuity) side or the resuscitation side of the department. If you wanted to work resus you could do that soley, but might need either a CCM fellowship or 1 year resuscitation fellowship.

I don't know if that's where things are headed or not, but it'd be kind of the ideal practice for a lot of EM folk I think. Work with only the sick ones while they're in the ED, and leave most of the primary care alone. Might just be a nice dream though; I'm too new to really have a good grasp on the landscape.

 

[pillowsnice]

EM in the US basically ranges from 90% primary care (large academic hospitals) to 95% primary care (small community hospitals). In an average week you'll treat 10-20 non emergencies for every true emergency. In a typical shift you see mostly non emergent headaches, back pain, abdominal pain, vomiting, dizziness, and weakness. This is in addition to all the frequent flyer nursing home residents, drug seekers, and alcoholics. Its nowhere near as exciting as it is on TV. The only exception would be working in the resuscitation bay at a busy inner city hospital. That's where all the truly sick and dying patients are treated. Unfortunately there's no such thing as a resuscitation residency and you spend most of your time working in the main emergency room.

Now I knew all of this going into EM but its one thing to be told that most of the job sucks and a whole other thing to experience it every day. Part of me was also hoping that there might still be a few ERs out there that only take care of real emergency patients. At least in the US this does not seem to be the case anymore and I don't expect things to change anytime soon. Don't get me wrong though, I still love taking care of those 10% of patients that are truly sick and need to be in the ER, its just that other other 90% can really suck some shifts. The only other specialty I seriously considered was anesthesia but its even more boring than EM 99% of the time. In addition you don't ever get your own patients and you don't ever get to fix anything except when things go horribly wrong in the OR a few times per year.

Does it sometimes feel unfulfilling when you get stuck with that 90% primary care patients? Are the variety of cases still exciting or does it get boring? Do you think you would be happier in another field where you treat the same types of things everyday?

 

[alpinism]

@alpinism Do you even lift, bro?

Every Monday, Wednesday, and Friday.

Gotta feed those pythons.

 

[alpinism]

I was recently listening to a podcast with Dr. Weingart and Dr. Mallemat where they were discussing critical care fellowships and why you should or should not do them. Scot Weingart made a comment about how he thought EM would soon evolve to where you would either work the EM (low acuity) side or the resuscitation side of the department. If you wanted to work resus you could do that soley, but might need either a CCM fellowship or 1 year resuscitation fellowship.

I don't know if that's where things are headed or not, but it'd be kind of the ideal practice for a lot of EM folk I think. Work with only the sick ones while they're in the ED, and leave most of the primary care alone. Might just be a nice dream though; I'm too new to really have a good grasp on the landscape.

Its funny you mentioned that since Weingart actually just started a resuscitation fellowship at Stony brook. In addition there are a few other resuscitation training programs scattered across the country. The only issue is that none of them are accredited since there's no board certification in resuscitation medicine.

I could write a whole book about the future of EM but there are definitely those in the EM world who would agree and think that the specialty is heading towards a great divide with some doctors focusing on low acuity patients and others focusing on high acuity patients. There are some EM docs out there who mainly work in the resuscitation bay/critical care room at major academic EDs however these jobs are very few and far between. The main issue is that there are just too many EDs out there and most EDs don't see anywhere near enough sick patients to support a full time EM/CC position. Even at the busiest US trauma centers you'll only average maybe 5-10 resuscitations per day. Its not uncommon at many trauma centers to go a whole day without a single resuscitation. As a result you would be limited to only a handful of hospitals nationwide. The other issue that many people don't think about is that nearly all of these places have residency programs with tons of residents needing to see patients and do procedures. This means that you would spend most of your time supervising residents rather than seeing your own patients and doing your own procedures.

 

[deleted647690]

Its funny you mentioned that since Weingart actually just started a resuscitation fellowship at Stony brook. In addition there are a few other resuscitation training programs scattered across the country. The only issue is that none of them are accredited since there's no board certification in resuscitation medicine.

I could write a whole book about the future of EM but there are definitely those in the EM world who would agree and think that the specialty is heading towards a great divide with some doctors focusing on low acuity patients and others focusing on high acuity patients. There are some EM docs out there who mainly work in the resuscitation bay/critical care room at major academic EDs however these jobs are very few and far between. The main issue is that there are just too many EDs out there and most EDs don't see anywhere near enough sick patients to support a full time EM/CC position. Even at the busiest US trauma centers you'll only average maybe 5-10 resuscitations per day. Its not uncommon at many trauma centers to go a whole day without a single resuscitation. As a result you would be limited to only a handful of hospitals nationwide. The other issue that many people don't think about is that nearly all of these places have residency programs with tons of residents needing to see patients and do procedures. This means that you would spend most of your time supervising residents rather than seeing your own patients and doing your own procedures.

I see you noted that EM in the US is mostly primary care, and resuscitation/ real emergency stuff is not that common in the US. If I was willing to relocate, would there be a country I could go to for practicing medicine where I'd be doing more of these types of things? Would doing something military related = more intensity?

 

[Monoloco357]

Reebok or Nike? If you can't decide, this should help you:

 

[The Buff OP]

Every Monday, Wednesday, and Friday.

Gotta feed those pythons.

I like that.

How's your residency going so far?

 

[alpinism]

Does it sometimes feel unfulfilling when you get stuck with that 90% primary care patients? Are the variety of cases still exciting or does it get boring? Do you think you would be happier in another field where you treat the same types of things everyday?

All the time. It's sort of like signing up for one specialty then being forced to practice another. Add on to that the fact that we don't really help any of these patients other than reassure them that they're not currently dying. Thousands of dollars spent on something that any FM clinic could have told them for a fraction of the cost.

The fact that we see a wide variety of patients is one of my favorite things about EM. I'd much rather see many different types of patients everyday rather than the same patients over and over again everyday. EM is as much about acuity as it is about variety. Ideally we're supposed to take care of the sickest patients regardless of their underlying medical condition.

 

[alpinism]

I see you noted that EM in the US is mostly primary care, and resuscitation/ real emergency stuff is not that common in the US. If I was willing to relocate, would there be a country I could go to for practicing medicine where I'd be doing more of these types of things? Would doing something military related = more intensity?

Real emergencies are going to be uncommon in any first world country. The difference is that in places like Canada, Australia, or New Zealand they have public healthcare systems and actively discourage people from using the ER for primary care. In the UK they actually have signs telling people not to go to the ER if they have a minor illness. In US we have signs telling people the average wait times for every ER in a 10 mile radius.

If you want to practice real emergency medicine you'll have to go places where most people don't want to live. Places like Brazil, Venezuela, Honduras, Afghanistan, and Yemen. You'll see very few if any true emergencies in the military unless world war 3 were to start tomorrow.

 

[deleted647690]

Real emergencies are going to be uncommon in any first world country. The difference is that in places like Canada, Australia, or New Zealand they have public healthcare systems and actively discourage people from using the ER for primary care. In the UK they actually have signs telling people not to go to the ER if they have a minor illness. In US we have signs telling people the average wait times for every ER in a 10 mile radius.

If you want to practice real emergency medicine you'll have to go places where most people don't want to live. Places like Brazil, Venezuela, Honduras, Afghanistan, and Yemen. You'll see very few if any true emergencies in the military unless world war 3 were to start tomorrow.

Thanks for the response. Have you known anyone that has desired true emergency work enough that they left the US and went to go work in one of those countries?

 

[alpinism]

Reebok or Nike? If you can't decide, this should help you:

Nike all the way.

Dude why all the WebMD hate??

Embrace the future of patient centered medical care: http://gomerblog.com/2015/12/non-physician-hospitals/

 

[alpinism]

I like that.

How's your residency going so far?

Not too bad. The hours are way better than I thought and I actually have a life outside the hospital. At the same time most shifts aren’t very exciting. For instance Thursday night was nearly all non emergent gyn complaints (lower abdominal pain and vaginal bleeding). You basically rule out all the badness (ectopic, torsion, abscess, etc…) and discharge. About once a week we do have an exciting shift though. On Monday night we had 3 gunshots and 2 heroin overdoses. Got to do a couple EJ IVs and put in a chest tube.

 

[Gurby]

Thousands of dollars spent on something that any FM clinic could have told them for a fraction of the cost.

There is an urgent care in my EMS service area, and the're usually good for sending out at least 3 patients via 911 during the ~12 hours they're open every day. It's always the people with a cold calling 911 for a ride to the ED, and the 50yo male with chest pain who drives himself to the urgent care. Super frustrating.

 

[The Buff OP]

Not too bad. The hours are way better than I thought and I actually have a life outside the hospital. At the same time most shifts aren’t very exciting. For instance Thursday night was nearly all non emergent gyn complaints (lower abdominal pain and vaginal bleeding). You basically rule out all the badness (ectopic, torsion, abscess, etc…) and discharge. About once a week we do have an exciting shift though. On Monday night we had 3 gunshots and 2 heroin overdoses. Got to do a couple EJ IVs and put in a chest tube.

That's good to hear. EJ IVs are always cool to see slide in.
What did you major in?

Do military residencies have the same work hours as civilian residencies?

 

[Monoloco357]

Nike all the way.

Dude why all the WebMD hate??

Embrace the future of patient centered medical care: http://gomerblog.com/2015/12/non-physician-hospitals/

Hahaha I don't completely disagree with it, but I do feel that the layman gets carried away with self-diagnosis. I think WebMD absolutely has its merits.

 

[alpinism]

Thanks for the response. Have you known anyone that has desired true emergency work enough that they left the US and went to go work in one of those countries?

I know a few who spend most of their time practicing outside the United States. For a variety of reasons its not a very popular career choice among EM physicians since you'd be giving up a great salary and quality of life plus moving away from all your friends and family.

The majority of physicians I know who work overseas are academic faculty who spend 1 to 3 months away per year. Most do a combination of clinical work, teaching, and research at university hospitals overseas. Its fairly easy to do at many residencies as long as they have a strong international EM program.