Minimal off service rotations

[docman85]

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What are some of the residency programs that have minimal off service rotations?

I have seen a few in researching such as Wake, Baystate, Geisinger, and MCG

 

[pinipig523]

Why would you want to do less off service rotations?

 

[docman85]

Correct my thinking here as I am still a 3rd year med student, but I like the idea of spending as much time as possible in the ED. I also like the idea of not having any general IM months but more ICU instead. If anyone has any advice as to things I should be considering please comment.

 

[pinipig523]

Correct my thinking here as I am still a 3rd year med student, but I like the idea of spending as much time as possible in the ED. I also like the idea of not having any general IM months but more ICU instead. If anyone has any advice as to things I should be considering please comment.

I think outside rotations strengthen you since they expose you to other specialties and you realize why and what makes for an appropriate consult.

Also a few gen med months helps you with understanding what goes on after you admit a patient with bread and butter diagnoses. ICU months are great as well.

But so is optho, ortho, ent, radiology, ob/gyn, anesthesia, etc.

 

[RustedFox]

Pinipig: I respectfully disagree. The key word is 'respectfully'.

Univ. of Toledo EM has minimal off-service months; with not a single "medicine floor" month. EM is best learned in the ED, and the faculty here understands that. The program is streamlined to minimize the time that residents are "note-writing machines" for other services.

On every single one of my off-service rotations, somewhere in the back of my brain was - "Jeezus, let me get back to the ED, as I'll never be doing _________ again." Sure, some of the learning was good... but it wasn't directed at what *I* needed to know first and foremost.

 

[turkeyjerky]

I think outside rotations strengthen you since they expose you to other specialties and you realize why and what makes for an appropriate consult.

Also a few gen med months helps you with understanding what goes on after you admit a patient with bread and butter diagnoses. ICU months are great as well.

But so is optho, ortho, ent, radiology, ob/gyn, anesthesia, etc.

Theoretically, isn't that what med school is for?

These threads always boil down the same: residents at programs w/ lots of off-service rave about how valuable their peds oncology clinic month was and how they couldn't imagine not having it, while others believe you should spend residency learning emergency medicine in the emergency department. As a current applicant who remembers the barren wasteland of my IM rotation, I'm inclined to agree with the latter. But while I struggle with my ROL, I'm coming to the conclusion that curriculum is not something that should make you pick a program you like less over a different one just cause they have a few more off-service months.

 

[Flopotomist]

I think you get better training by having a reasonable amount of appropriate off-service rotations. Some things you just aren't going to see enough of in the ED, so doing time on that service really helps. Example - labor and delivery.

Medicine floor month sucks - no way around that, but it DOES help build relationships with your medicine colleagues which makes admitting patients to the medicine floor WAY easier (hard to be a jerk and block an admission from your friend).

In my program (Wash U in St Louis) we do cardiothoriacic ICU (put in a TON of chest tubes all month) neuro/neurosurg ICU (managing mannitol, head bleeds, bolts etc), peds ICU, surgical ICU, radiology, toxicology, orthopaedics, L&D, surgery peds and medicine floor (1 month each).

For each of the rotations I have done I have learned SOMETHING that has helped me at some point in the ED - something that I could not have learned from doing every day in the ED alone.

 

[pinipig523]

Theoretically, isn't that what med school is for?

These threads always boil down the same: residents at programs w/ lots of off-service rave about how valuable their peds oncology clinic month was and how they couldn't imagine not having it, while others believe you should spend residency learning emergency medicine in the emergency department. As a current applicant who remembers the barren wasteland of my IM rotation, I'm inclined to agree with the latter. But while I struggle with my ROL, I'm coming to the conclusion that curriculum is not something that should make you pick a program you like less over a different one just cause they have a few more off-service months.

No.

I'd like for you to try to place an optho consult properly or to use the slit lamp properly. Do you know how to do oral blocks? Do you know how to read an echo? Do you know what an epoint parameter is in determining the probability of decompensated CHF? Do you know how to properly reduce perilunate dislocations?

No offense, but from my experience - M4 or incoming interns know very little medicine.... especially after that long vacation right after interviews and before residency. Myself included.

And to drive the point home - I'm not one of those residents of an off-service heavy program... pointlessly defending the utility of off service rotations - I come from a program that has more EM months than any other 3y program around.

I chose a 4y program so I could have more time to explore what's outside the ER... but things that would help me considerably in the ER.

Of course, it's your choice. And I'm sure you'll turn out fine.

 

[pinipig523]

I think you get better training by having a reasonable amount of appropriate off-service rotations. Some things you just aren't going to see enough of in the ED, so doing time on that service really helps. Example - labor and delivery.

Medicine floor month sucks - no way around that, but it DOES help build relationships with your medicine colleagues which makes admitting patients to the medicine floor WAY easier (hard to be a jerk and block an admission from your friend).

In my program (Wash U in St Louis) we do cardiothoriacic ICU (put in a TON of chest tubes all month) neuro/neurosurg ICU (managing mannitol, head bleeds, bolts etc), peds ICU, surgical ICU, radiology, toxicology, orthopaedics, L&D, surgery peds and medicine floor (1 month each).

For each of the rotations I have done I have learned SOMETHING that has helped me at some point in the ED - something that I could not have learned from doing every day in the ED alone.

Agreed.

 

[pinipig523]

Pinipig: I respectfully disagree. The key word is 'respectfully'.

Univ. of Toledo EM has minimal off-service months; with not a single "medicine floor" month. EM is best learned in the ED, and the faculty here understands that. The program is streamlined to minimize the time that residents are "note-writing machines" for other services.

On every single one of my off-service rotations, somewhere in the back of my brain was - "Jeezus, let me get back to the ED, as I'll never be doing _________ again." Sure, some of the learning was good... but it wasn't directed at what *I* needed to know first and foremost.

RF,

I will respectfully disagree AND agree.

While I do see your point about wanting to go back to the ED, I feel that after a certain number of months in the ED, you've experienced what you need to feel proficient.

I do think that off service rotations allow you to come back stronger and better than before (almost like an upgrade in skills).

Another reason why I chose a 4y program.

 

[RustedFox]

There is an "appropriate" number of off-service rotations that are mandated by the RRC. OB/GYN, MICU, etc.

I'm not going to argue that those bits of esoteric knowledge aren't useful. They are; - but they're such rare animals in everyday ED practice, and in reality... situations like that are frequently handled as: "get them to the appropriate service, because I have eleventeen other things to do".

Example: My program recently ditched our SICU month in favor of a different ICU month, which I feel was a good move. During my SICU month, all I did was watch surgical residents call each other idiots and grumble about the "appropriate" way to manage (whatever) and attempt to elbow each other out of the way to do (whatever). Didn't teach me a bunch, but it did remind me of why I went into EM.

 

[pinipig523]

There is an "appropriate" number of off-service rotations that are mandated by the RRC. OB/GYN, MICU, etc.

I'm not going to argue that those bits of esoteric knowledge aren't useful. They are; - but they're such rare animals in everyday ED practice, and in reality... situations like that are frequently handled as: "get them to the appropriate service, because I have eleventeen other things to do".

Example: My program recently ditched our SICU month in favor of a different ICU month, which I feel was a good move. During my SICU month, all I did was watch surgical residents call each other idiots and grumble about the "appropriate" way to manage (whatever) and attempt to elbow each other out of the way to do (whatever). Didn't teach me a bunch, but it did remind me of why I went into EM.

Agreed, useless off service rotations just to keep a body there is dumb.

I will have to say that electives are great. You get to choose what you want to explore and what you want to hone.

I have lots of electives this year and I'm using to make sure I'm level 3 with ultrasound, reading CTs, refining my knowledge of toxicology, etc.

I think that 4mo of floor work (ICU and gen) is good enough for that part of medicine. 2wks of anesthesia, OB are good. In addition to trauma, peds obviously.

The rest should just be electives. So you can explore optho, ent, omfs, etc.

 

[otacon88]

I know U of Louisville has almost no floor months, except maybe 1 or 2 ICU.

 

[deuist]

My program does no floor months. For PGY-1's, half of the year is off service in places like MICU, NICU, and L&D. PGY-2's have only a couple of off service months. And third is entirely in the ED except for electives.

 

[StevieStud]

Isn't EM suppose to be a bit of a cowboy, the jack of all trades ready to tackle just about anything that rolls through the door without having to wait for backup to arrive from the 3rd floor?

If that is true, then learning how to write discharge notes for GS/IM and other waste of time scut work might not help your education goals but surely there is something you can learn from the other departments that will make you a better EM doc.

 

[pinipig523]

Isn't EM suppose to be a bit of a cowboy, the jack of all trades ready to tackle just about anything that rolls through the door without having to wait for backup to arrive from the 3rd floor?

If that is true, then learning how to write discharge notes for GS/IM and other waste of time scut work might not help your education goals but surely there is something you can learn from the other departments that will make you a better EM doc.

How do you become a jack of all trades if the only thing you were exposed to is the ER? You just become the jack of the ER.

I'm not saying let's do half the year on the floors... I'm saying let us see what the other services do and ask them this question: What do you wish the ER knew and how do you want the ER to make use of you as a consultant?

Those are things I ask every rotation I go through - you learn a lot this way.

Atleast I do. You can do whatever you want.

 

[RustedFox]

My program does no floor months. For PGY-1's, half of the year is off service in places like MICU, NICU, and L&D. PGY-2's have only a couple of off service months. And third is entirely in the ED except for electives.

I frequently give the following speech to applicants at the pre-interview dinner:

"There are three kickass things about our program..

1.) No floor months. Any program that has you doing more than one medicine floor month is using you as a note-writing machine.
2.) Not a single on-service attending is malignant.
3.) Three electives in your senior year. No off-service months. Do what you want to, not what the institution 'deals' you to do as part of some interdepartmental bargain."

Speaking personally, I used those elective months to temper those skills that I thought I would need in the niche markets that I was trying to break into.

Fact of the matter: EM is a unique animal altogether. Sure, you can learn X-Y-and-Z from your scandanavian-paediatric-hematology-whatever month... but out in the community... you spend five minutes making sure that "that" patient isn't going to die, immediately... then you coordinate care to move them to whatever service is most appropriate, because EMS is going to keep hammering your back door. Again. and again...

 

[RustedFox]

... and furthermore... here's the best part about 'community' versus 'academic' EM... the community admitting/subspecialty crews are happy that you were there to see/stabilize/call and give them a heads-up as to the situation.... the 'academic' services are just looking for the chance to belittle you for being a "dumb ER doc" when you don't know that patients with factor-eleventeen-deficiency benefit from unicorn farts 58-93 hours after electrojudotherapy.

...


Meanwhile.. LifeSquad 99 is fourteen minutes out with a 68 year old male with SOB.

...

and then MedCorp 34 is coming in with a full arrest. And its a wintery night in the midwest... with idiots who can't drive ...

 

[Daiphon]

I thought I just saw a Japanese study showing greater mortality with the use of unicorn farts... Wait, that was dabigatran... Wait again, same thing. d=)

All-in-all, the off service thing boils down to 'different strokes for different folks.' however, it shouldn't be the basis for your ROL.

-d

 

[RustedFox]

Waaait - I read that study too... you've got it wrong; it was the electrojudotherapy (as opposed to hydrojudotherapy), not the unicorn farts that resulted in the increased mortality.

 

[deuist]

Getting people admitted to community hospitals is so much faster, too. Whenever I call the hospitalist at the community ED, the conversation goes something like:

Me: I need to admit Jones Smith with chest pain.
Him: Okay, thanks. (Click)

At the academic center, I have to make multiple phone calls to different departments, residents, and sub-specialists and give lengthy presentations where a medicine resident will invariably start asking me about the MCV on a pneumonia patient with normal hemotacrit.

 

[RustedFox]

Getting people admitted to community hospitals is so much faster, too. Whenever I call the hospitalist at the community ED, the conversation goes something like:

Me: I need to admit Jones Smith with chest pain.
Him: Okay, thanks. (Click)

At the academic center, I have to make multiple phone calls to different departments, residents, and sub-specialists and give lengthy presentations where a medicine resident will invariably start asking me about the MCV on a pneumonia patient with normal hemotacrit.

Yuuuuuup. Community medicine FTW.

 

[Daiphon]

Waaait - I read that study too... you've got it wrong; it was the electrojudotherapy (as opposed to hydrojudotherapy), not the unicorn farts that resulted in the increased mortality.

RF -
My apologies for the confusion; thanks for the clarification on yet another reason to NOT use electrojudotherapy.

-d

PS - I'm totally stealing that term. d=)

 

[pinipig523]

rf -
my apologies for the confusion; thanks for the clarification on yet another reason to not use electrojudotherapy.

-d

ps - i'm totally stealing that term. D=)

lol!!!

 

[Arcan57]

I thought I just saw a Japanese study showing greater mortality with the use of unicorn farts... Wait, that was dabigatran... Wait again, same thing. d=)

All-in-all, the off service thing boils down to 'different strokes for different folks.' however, it shouldn't be the basis for your ROL.

-d

I will come out as a big proponent for not doing floor months in IM. If you're looking for comaraderie, unit months work just as well (CCU and MICU). If you're doing them expecting that your fellow intern isn't going to be obstructionist in two years when you're trying to admit someone for social reasons, that's a thin hope.

 

[RustedFox]

Wait. Which term are you stealing ? Electrojudo, hydrojudo, or Unicorn Farts.

You're welcome to all three, for the record.

 

[Daiphon]

Electrojudo...

I already have a can of unicorn meat (thinkgeek.com).

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