NEW EMERGENCY MEDICINE RESIDENCY

[gro2001]

I'm not sure how you could possibly think this is a good thing? EM will end up like pathology and rad/onc. Too much supply without any demand plus the dangers of continued CMG proliferation, you'll be barely making enough to pay your loans and living in an apartment.

There is more supply, yes, but I would challenge you on the demand. Population is getting older, hospital visits are increasing, more physicians are choosing to work less. If we are just throwing our impressions around, I don't think we are oversaturated. Some specific markets, maybe.

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[gro2001]

I guess I'm in the minority here in that I was trained by very competent PEM physicians who managed acute patients well.

At the end of the day, your average EM residency has 6-8 months of PEM, while a PEM fellowship has 20-22 months. This doesn't take into account pre-fellowship experience. All that exposure counts for something, in my opinion.

Yes, but the question was about sick kids. In my subjective opinion, that's the primary measure of how good an emergency physician is in the pediatric setting. Everything else is secondary. PEM fellowship gives you more exposure to kids, but EM residency gives you way more exposure to sick. While some people think that the way to learn to be good at resuscitating sick kids is to get good with kids in general and then get some exposure to sick kids, I would argue that you are far better served first developing a solid basis in resuscitation and then learning how certain aspects change in relation to kids. Pediatricians have scared everyone for years with the mantra of "kids are not just small adults", but I would argue a different mantra is more applicable: shock is shock. There are nuances, but in general how good someone is at resuscitating kids is largely a factor of how many patients in extremis they've resuscitated, rather than how many kids they saw. And you get a lot more exposure to extremes of physiology in EM residency than in Peds residency + fellowship.

 

[deuist]

I would also like to believe that I was trained by competent pediatric emergency physicians. However, the specialty's own literature suggest that fellows are not adequately trained in procedures.

http://pemcincinnati.com/blog/wp-co...of-critical-procedures-performed-in-a-PED.pdf

 

[gro2001]

I would also like to believe that I was trained by competent pediatric emergency physicians. However, the specialty's own literature suggest that fellows are not adequately trained in procedures.

http://pemcincinnati.com/blog/wp-co...of-critical-procedures-performed-in-a-PED.pdf

Thanks for bringing it up. I think this paper demonstrates this point really well.

To highlight a specific part: (this is them looking at the preceding 12 months) "no fellow performed a central venous line placement, needle thoracostomy, or pericardiocentesis in the pediatric ED during the study period. Only half of the fellows performed an intraosseous line placement, and just 30% performed a tube thoracostomy. Fellows performed a median of 2.5 orotracheal intubations compared with a faculty median of zero, but 40% of the fellows performed 1 or fewer. The adult anesthesia literature suggests that approximately 50 to 60 intubations are required to achieve competence."

The Cincinnati PEM fellowship is generally regarded as an excellent program. And they deserve a lot of credit for publishing this paper (which made quite a stir when it came out). But the bottom line is that even at this excellent program, the median fellow would graduate with <10 intubations in the ER. Sure, they may have 'procedural electives' and time in the OR and such to augment it, but we all know that's not equivalent.

Perhaps more importantly, and not addressed in this paper, is the non procedural aspect of resuscitative decision making. That's a lot harder to track and figure out how much exposure they are getting, but considering that resuscitations make up 0.22% of their volume, I suspect that PEM fellows also don't get a huge amount of exposure to that type of critical decision making either.

 

[miacomet]

There is more supply, yes, but I would challenge you on the demand. Population is getting older, hospital visits are increasing, more physicians are choosing to work less. If we are just throwing our impressions around, I don't think we are oversaturated. Some specific markets, maybe.

EM visits are down nationwide per Modern Healthcare, and not insignificantly.

 

[cyanide12345678]

EM visits are down nationwide per Modern Healthcare, and not insignificantly.

Agreed. Almost all the hospitals in my area have seen a decline of 5% volume roughly over the last few years. A large component of this is likely because of the urgent cares which are taking away some of the low acuity volume.

 

[miacomet]

Agreed. Almost all the hospitals in my area have seen a decline of 5% volume roughly over the last few years. A large component of this is likely because of the urgent cares which are taking away some of the low acuity volume.

Yup. And the low-acuity patients actually keep the ED solvent. Lacerations and fractures are reimbursed well, while sick folks are money losers. It's a shame that ER hasn't assumed control of the UCs and kept them under the ED umbrella.

There will be clinical jobs for EM docs, but they might be telehealth or UC. Caveat emptor.

 

[Hercules]

Yup. And the low-acuity patients actually keep the ED solvent. Lacerations and fractures are reimbursed well, while sick folks are money losers. It's a shame that ER hasn't assumed control of the UCs and kept them under the ED umbrella.

There will be clinical jobs for EM docs, but they might be telehealth or UC. Caveat emptor.

I can’t think of any conceivable way that EM could have tried successfully to keep UC under its umbrella. I also wouldn’t be willing to only
hire board certified EM docs to staff my urgent care. For the most part, its a waste of their skills and overpaying then for a fast track job. Working in an UC is not a good transition job for burned out EM docs. Put up the capital, open the UC, get it running well, and then staff it and enjoy the passive income.


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[GeneralVeers]

The questionable residencies continue. Envision in Las Vegas is going to start an EM residency at two of their community hospitals. The supporting "medical school" is named Roseman University, and they have only just now finished their accreditation for starting up their medical school. Shady stuff.

 

[miacomet]

Roseman is one of the new breed of sketchy for-profit medschools. Terrible.

 

[Apollyon]

Roseman is one of the new breed of sketchy for-profit medschools. Terrible.

No, actually, from what I saw online, they're non-profit.

 

[miacomet]

No, actually, from what I saw online, they're non-profit.

Cool- aren't some of the new DO schools for-profit? Like Rocky Vista? Maybe that's the one I was thinking of.

 

[Apollyon]

Cool- aren't some of the new DO schools for-profit? Like Rocky Vista? Maybe that's the one I was thinking of.

Yeah, at least Rocky Vista, but I think that there's more. What the hell, man? I'm proximate to LECOM, and I describe that as a puppy mill. Now, for-profit? Bogus.

 

[Mad Jack]

Hate to say it as I have PEM friends, but can't agree more. Every airway handled by a PEM person is "tricky." Sick children are best left to EM trained folks for initial stabilization with guidance from real "sick kid" doctors - aka PICU. PEM is glorified clinic.

I went through a peds ED that was probably one of the highest volume ones in the country, they were actually pretty decent at airway management. If anything the PICU staff worried me because I felt like they were just throwing the kitchen sink at everything and not using evidence-based medicine to any degree ever.

 

[Hamhock]

The questionable residencies continue. Envision in Las Vegas is going to start an EM residency at two of their community hospitals. ... Shady stuff.

This has been going on for a while. Many of the DO residencies have been sketchy for years. More than a few of the allopathic residencies have been poorly preparing graduates for years.

It has always bothered me when folks on this forum state that all EM residencies produce adequately-trained EM docs...supported by some RRC criteria babble.

There is a far greater range of quality in the world of EM than is acknowledged here. Perhaps a dogma is starting to die.

That said, this trend still makes me sad.

HH

 

[miacomet]

This has been going on for a while. Many of the DO residencies have been sketchy for years. More than a few of the allopathic residencies have been poorly preparing graduates for years.

It has always bothered me when folks on this forum state that all EM residencies produce adequately-trained EM docs...supported by some RRC criteria babble.

There is a far greater range of quality in the world of EM than is acknowledged here. Perhaps a dogma is starting to die.

That said, this trend still makes me sad.

HH

Agreed, and I would also add that many of the vaunted county programs aren't that well received by certain SDGs. Customer service is important, as is working WITH your consultants. It's not all about being a cowboy. I have seen plenty of inadequately trained glads, and plenty of county grads with a god complex.

 

[deuist]

Last I heard, my hospital still wants to open an EM program within a year. We still don't have a program director. When I look at what we have to offer in terms of specialists, I think that we would make an excellent unopposed family medicine program. We need primary care docs. I don't know why we aren't pushing for more.

 

[miacomet]

Last I heard, my hospital still wants to open an EM program within a year. We still don't have a program director. When I look at what we have to offer in terms of specialists, I think that we would make an excellent unopposed family medicine program. We need primary care docs. I don't know why we aren't pushing for more.

They won't staff the ER...

 

[deleted109597]

They won't staff the ER...

And they aren't required by law to have primary care, but the ER needs to have bodies.
@deuist, is your ER by any chance staffed by a CMG?

 

[emergentmd]

CMGs opening up residencies is what will Wreck our field. When you let these for profit groups whose sole mission is make money, they will find the best way to fix their cost issues. Currently its ER doc pay. The way to fix this is produce more, flood the market. Easy supply and demand.

I am glad I have 5-10 more yrs of this which is when the flood will come.

 

[deuist]

@deuist, is your ER by any chance staffed by a CMG?

Yep