Losing EM skillset at low volume?

[cyanide12345678]

Actually, this is dependent on the FSED. If you’ve seen one FSED........you’ve seen one FSED.

In the past 10+ years I have often found that an ambulance ride is not a hip, skip, or jump away to our tertiary care center that is 15 min away (where I also work). When a true emergency rolls in— you’re it, often working with less resources. (I.e. we don’t carry blood products at our FSED). We also take EMS traffic. I’ve done every procedure sans a perimortem section, burr holes, and thoracotomy at our FSEDs.
My unsolicited opinion to the OP:
Find out what your FSED can and cannot do. Next, write a list of what you can and cannot tolerate. Thinking low volume is low acuity is short-sighted. Talk to the docs who work there. Then you can draw your own conclusion.

Acuity i don't mind at all. I can handle sick patients without backup. My current shop, 20k volume single coverage has very few specialist services. And sometimes there are a lot of transportation delays. I've had days where I'm running an ICU because patients aren't getting out. My hospitalists do not feel comfortable keeping moderately sick patients. Life gets pretty interesting when flight is not flying and we have 1 transportation truck that will take 3 hours to make a back and forth trip to the nearest tertiary hospital and multiple sick patients are waiting in line for transfer.

So acuity isn't the issue, large boluses of volume is what's exhausting. Taking care of sick patients without a bunch of other people with silly things will probably be refreshing. I would really enjoy doing a procedure where I'm not constantly wondering what the department is going to look like when i walk out -_-

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[Arcan57]

Will also chime in that 8k/yr at FSED and 8k/yr at rural hospital aren't going to be equivalent. That breaks down to about 22 pts/day which if you're single coverage 24s is a reasonable volume. If it's a critical access hospital, some of those people are going to be stupidly sick. Also their arrival will be clustered in the evening so you'll get a rush of 7-10 pts in a couple of hours a decent amount of the time.

 

[Groove]

I really don't think skill atrophy is always a concern with low volume sites. Are you going to see lower frequency acuity....sure. However, when you do see a real emergency, you have to get damn creative as you have limited resources and usually limited hands on deck in the hospital, especially at odd hours of the night. That can lend to some cases where you are doing a great deal of CC and wearing multiple hats so to speak. Some of these low volume sites can be ball buster shifts and the guys staffing them have to be real cowboys so pay attention to the volume, transfer rate, admission rate, % peds, % OB, pph, etc.. and do your due diligence. Some of my most memorable, high acuity and "crazy" cases were from low volume ERs out in the middle of nowhere. I really wouldn't worry though about skill atrophy. You're 5+ years including residency and that's plenty of time for your skills to gel IMO. If you want my honest opinion, I think high volume, academic sites have potential for greater skill atrophy than a low volume community site. In many of those places you've got consultants or residents doing all your procedures, etc.. I worked in a 70-80K/yr really busy level 2 trauma center out of residency and I did way more procedures at my next 60K community site than I did at the busy trauma center. At the trauma center, our intensivists would put in all the lines and never expected the ED to do it and I probably felt the most like a triage doc at that site. I'm probably exaggerating the lack of procedures but you get my drift.

The 1 hr commute kind of bites IMO but then again I'm 2.5 minutes from my job, so I'm biased. 0.8pph? 24h shifts? Do they cap your hours? If not, go with the low volume site and even if it's not what you dreamed....stick it out 3-4 years and put the money towards retirement. You can work in excess of 200 hours at slow sites like that and never feel it unlike a busy trauma center or community site where anything over 150-160 burns you out quick. I had a friend who worked in a FSED for a few years with volume like that, cranking out 24s and was making 6-700K/yr. Even if you don't want to work that many hours, you'll have loads of time off for other pursuits and if memory serves you have a great deal of entrepreneurial outside interests so that type of job might serve you well.

 

[WilcoWorld]

I would really enjoy doing a procedure where I'm not constantly wondering what the department is going to look like when i walk out -_-

If anyone knows such a gig - please PM me.

 

[cyanide12345678]

I really don't think skill atrophy is always a concern with low volume sites. Are you going to see lower frequency acuity....sure. However, when you do see a real emergency, you have to get damn creative as you have limited resources and usually limited hands on deck in the hospital, especially at odd hours of the night. That can lend to some cases where you are doing a great deal of CC and wearing multiple hats so to speak. Some of these low volume sites can be ball buster shifts and the guys staffing them have to be real cowboys so pay attention to the volume, transfer rate, admission rate, % peds, % OB, pph, etc.. and do your due diligence. Some of my most memorable, high acuity and "crazy" cases were from low volume ERs out in the middle of nowhere. I really wouldn't worry though about skill atrophy. You're 5+ years including residency and that's plenty of time for your skills to gel IMO. If you want my honest opinion, I think high volume, academic sites have potential for greater skill atrophy than a low volume community site. In many of those places you've got consultants or residents doing all your procedures, etc.. I worked in a 70-80K/yr really busy level 2 trauma center out of residency and I did way more procedures at my next 60K community site than I did at the busy trauma center. At the trauma center, our intensivists would put in all the lines and never expected the ED to do it and I probably felt the most like a triage doc at that site. I'm probably exaggerating the lack of procedures but you get my drift.

The 1 hr commute kind of bites IMO but then again I'm 2.5 minutes from my job, so I'm biased. 0.8pph? 24h shifts? Do they cap your hours? If not, go with the low volume site and even if it's not what you dreamed....stick it out 3-4 years and put the money towards retirement. You can work in excess of 200 hours at slow sites like that and never feel it unlike a busy trauma center or community site where anything over 150-160 burns you out quick. I had a friend who worked in a FSED for a few years with volume like that, cranking out 24s and was making 6-700K/yr. Even if you don't want to work that many hours, you'll have loads of time off for other pursuits and if memory serves you have a great deal of entrepreneurial outside interests so that type of job might serve you well.

Good advice. Greatly appreciated. They are figuring out contract details and sending an official offer, but yeah looks like I'm going full time rural. Yeah the acuity is still decent, i think 2 transfers a day minimum plus one or two admissions. I don't think i would work more than 6-7 24s a month. With my wife becoming a family medicine attending, between the two of us, we will break 600k in income. At that point, i don't think more money adds anything to our lives. I think time with our kids is probably more valuable.

 

[deleted6669]

I really don't think skill atrophy is always a concern with low volume sites. Are you going to see lower frequency acuity....sure. However, when you do see a real emergency, you have to get damn creative as you have limited resources and usually limited hands on deck in the hospital, especially at odd hours of the night. That can lend to some cases where you are doing a great deal of CC and wearing multiple hats so to speak. Some of these low volume sites can be ball buster shifts and the guys staffing them have to be real cowboys so pay attention to the volume, transfer rate, admission rate, % peds, % OB, pph, etc.. and do your due diligence. Some of my most memorable, high acuity and "crazy" cases were from low volume ERs out in the middle of nowhere. I really wouldn't worry though about skill atrophy.

This. At a rural place you won't have residents and specialists doing the procedures and whisking the pts away to the ICU. A good friend of mine is an attending at an academic medical ctr ED and works per diem at one of my rural facilities. He said the only time he ever feels like an emergency physician is when he works the rural shifts because you see every patient and do every procedure. My procedural numbers went through the roof when I moved from an urban setting to very rural critical access hospitals.

 

[southerndoc]

Let's get back on topic here... "Losing EM skillset at low volume?"

 

[southerndoc]

Moving to the off-topic forum so everyone can bash it out off the forum. SDN created a forum just for that purpose.

EDIT: Separated out the off-topic posts and moved them to the Off-Topic Forum.