Off service residents "cherry-picking" EM patients

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odyssey2

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If you have prelims/FM residents rotating on EM, have you guys had issues with them picking up too few patients or cherry-picking the easy ones? How have you dealt with this?
 
Unless you are part of their ED evaluations, there's little that can be done. I mean, you can escalate the issue to their PD but this usually results in transient behavior modification with time delayed relapse back into old patterns from my experience. We had an FM residency that rotated through my last gig and they would just...basically hide or not show up, or leave 5 hours early, or pick up all the simple URIs, etc.. We didn't really care to be honest. Who wants to work with a resident not interested in learning? In my opinion, it's not worth getting upset over. It's their education. If they want to short change themselves, then go for it. Sometimes, I would just send them home if they were exceedingly lazy or had a bad attitude. I wouldn't even report it to their PD, I truly just didn't care and as long as they were out of the ED and out of my hair, that was good enough.

Currently, I'm working in an EM residency and we have IM residents that rotate with us but we are involved in their evaluations and as can be expected, their behavior is light years better than the previous hospital's FM residents. Very hard workers, very involved, interested in learning, etc.. Not too shocking considering that we fill out their evals.
 
My experience echos above. Our FM residents are extremely lazy. Sometimes don't even show up. Have issues finishing their charts. Have random questionable "didactics" "guest lecture" or "clinic" at odd times. We essentially just send them to the urgent care side now and they can see their 0.5pph.
 
odyssey2 said:
If you have prelims/FM residents rotating on EM, have you guys had issues with them picking up too few patients or cherry-picking the easy ones? How have you dealt with this?
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Nope, we assign patients to them.
 
emergentmd said:
All Off service residents/interns sucks and should be treated as med students. This included EM residents in off service too. I surely have slacked when on off service.

I did my share of hiding on OB/GYN for sure.
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Wasn't gonna say anything but since you brought it up that was my exact thoughts

My OB experience: "I'll be in the hospital gym, call me if you want me to help deliver a baby"

*after mandatory 10 deliveries*

"I'll be in the hospital gym, don't call me"

Had to do two weeks of ortho clinic and two weeks of nights on my ortho rotation. The nights were good, lots of reduction experience in the ED. the clinic sucked and was pointless, did one day of it and just skipped the rest of the two weeks of clinic. No one said anything, cared or noticed.

Yeah, hard for me to **** on an off service residents in the ED. If they want to see one forearm laceration in 8 hours, sobeit. I don't say anything.
 
Rekt said:
My experience echos above. Our FM residents are extremely lazy. Sometimes don't even show up. Have issues finishing their charts. Have random questionable "didactics" "guest lecture" or "clinic" at odd times. We essentially just send them to the urgent care side now and they can see their 0.5pph.
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You guys need to toughen up with that. We've had residents have to come on their off-service months to make up shifts.
 
This partially falls upon the senior residents in the pod. A good senior will ensure that they are pushing the off service residents to see more patients, and unpleasant ones (vaginal bleeding, psych patients, lac repairs). In addition, they should be there to support/supervise/oversee them as well in addition to the attending.

When I was a senior resident, I would tell them: I'm going to pick up the next 2 patients, can you please see the new patient they slotted in room 31. You would inevitably get an eye roll or a sigh. You would watch them drowning while they were juggling the 3 patients they had on the board, but ultimately you aren't there to be their friend. It's important for them to get to see why EM is like so when they block consults/admissions as seniors they understand what the ED deals with on a daily basis.
 
I wish we could have more input on evals as I agree that would help. The FM and IM residents have varying work ethics. I’ve had a few that really wanted to learn and work. I push those residents but make sure they also aren’t taking on too much. Very much like an EM intern very early on in their training. I’ve had one ortho resident push himself to actually remember his med school medicine too, picking up syncope patients. Poor guy won’t remember any of that by the end of residency but at least he was willing to push himself. Documentation from the off service residents is usually decently suspect as well.

The way I approach it is giving them a reason for why this can be helpful for them: working on their patient efficiency. My father was a primary care doc. He would usually see upwards of 30 to 40 patients in a 9 hour work day every weekday including acute visits. That was how he made money as a primary. I explain that improving their efficiency now and being able to move fast but accurately will allow them to earn more than their peers over the long run. They usually understand that. With them becoming employed docs, this may not be a big deal until their group is losing money. Most don’t want to do procedures, but office procedures like wart removals and lac repairs are where a primary care doc can really increase their income. They don’t like hearing that and don’t want to get involved in procedures at all, which is fine. At least they understand the trade off they’re making then.

Trying to set any firm boundaries for them doesn’t work in my experience and the majority of the time, if they aren’t motivated by that discussion then there’s nothing to help them along. I just let them be and whatever they see hopefully doesn’t slow me down much.
 
It was annoying when I was in residency. That said, the more you see the better you'll get.

Residency sucks. Then it's over.
 
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odyssey2 said:
If you have prelims/FM residents rotating on EM, have you guys had issues with them picking up too few patients or cherry-picking the easy ones? How have you dealt with this?
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During my academic attending days I honestly was annoyed by how much energy my residents put into this issue. Life ain’t fair. Sorry the psych intern isn’t “pulling their weight” etc
 
It’s funny because during my EM rotation during my IM residency I was told that my job was to pick up the easy patients so the EM residents can see the “real patients.”


I’d much rather had seen the actually sick patients. Apparently off service residents in EM can’t win. Either they don’t pull their weight seeing complex patients, or they aren’t supposed to see a anything worse than a fast track patient.
 
If I have both EM and off-service in the pod, I just ask them what their goal is from EM.

The optho prelim (while smart and hardworking) does not need nor likely want to see a ADCHF patient or a stable polytrauma. Whereas the FM resident who may want to work in 1000 visit ER 6 hours from a city may want to see those patients. I tailor their patients to their goals, the EM residents or me will see it all in between whatever patients they take. Most of the time they lack the foundational thinking to thrive in EM so they need more guidance on their 4 week rotation than an EM intern. In my experience it is also really not safe for most off service residents to carry more than a few patients at a time as things will get lost.

EM residents/interns load will always be a lot more than an off service. Its expected and needed for growth in training.
 
I particularly enjoyed rotating on ICU with an off-service EM resident in charge of the unit

Watching him valiantly trying to block referrals from his own department was a sight to behold
 
So, I mention this only for context. I was a resident at Duke. Think of "Duke Internal Medicine". In my grad year, exactly ZERO went into general IM. EVERY single one did a fellowship. In the ED, one pt every two hours was VERY common. However, there was one exception: one resident, who went on to Heme/Onc, joined as many traumas as she could, and really tried. It was enough that trauma welcomed her.

However, as I say, singular.
 
This is something that bites us in the butt later, guys.
These off-service residents leave with the impression that "EM is so easy" and then develop amnesia as to the fact that they did this cherry-picking. This is unlike the experience we all have in surgery rotations, so we naturally respect their field more (since we remember it as grueling).
We ought to be strict with these residents and also make them feel the heat, especially with the sicker/acute patients. (Senior residents should actually be making sure everything goes right as far as clinical care, but at least pimp a little bit here.)
 
As a former off-service resident, I will say that I always grabbed the next chart in the rack and, if it seemed like something the EM intern would like to take (aka, a possible procedure), and they weren't already getting killed, I'd offer it to them and if they said no, walk in the room and get to work.

That said, I was definitely slower than anyone else in the department, but didn't stop moving.

You basically have to decide if it's worth the trouble to coach them along, or just get them out of the way so you can get the work done.
 
TheComebacKid said:
This partially falls upon the senior residents in the pod. A good senior will ensure that they are pushing the off service residents to see more patients, and unpleasant ones (vaginal bleeding, psych patients, lac repairs). In addition, they should be there to support/supervise/oversee them as well in addition to the attending.

When I was a senior resident, I would tell them: I'm going to pick up the next 2 patients, can you please see the new patient they slotted in room 31. You would inevitably get an eye roll or a sigh. You would watch them drowning while they were juggling the 3 patients they had on the board, but ultimately you aren't there to be their friend. It's important for them to get to see why EM is like so when they block consults/admissions as seniors they understand what the ED deals with on a daily basis.
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This is an interesting take. One I'm sympathetic to, and I think it helps clarify the question.

Should I make off-service rotators see patients they don't want to in the ED?

If your goal is to give the best patient care - hell no.
If your goal is to serve their education - depends on the patient.
If your goal is to teach the senior EM resident how to run an ED - maybe.
If your goal is to show them what working in the ED is like - yes, and better make 'em interpret an ECG while they're arguing with Radiology to do a CT that you don't really think is EMERGENTLY indicated, but you need to get to admit this patient and possibly will (in some way) serve the patient.

If your goal is to be fair - let me tell you this now, Medicine isn't fair.
 
Every once in a while we get a resident who actually cares. MOst of them are there to get through the rotation. I will have them pick up patients I don't want to deal with but wont add to my workload. I see all the psychs. If we have an OB residents I have them see all the lower belly pelvic issues in women. If they arent engaged I use them like a glorified scribe ecept I usually have the scribe do their note cause it takes 5x more work to correct their note than have my scribe do the note for me.
 
You don’t want easy patients in residency. You want the hardest, craziest, non-sensical, dizzy, fatigued, chest pain, altered mental status, 80 year old, pregnant, male, unicorn you can find. You’re learning on someone else’s malpractice so don’t skimp on the hard ****.
 
Remember this when advising the EM resident when they are off service …where I did residency the EM residents had the whole day on Wednesdays for their diadactics…but of course never attending any of the IM one… and generally had lower pt load with the easier pts in the icu… and someone else had to take their pts on their “lecture” days…sometime you get what you give…
My goal on that 4 week rotation was to get my required Pelvic exams ( which I never did again)and not admit anyone to medicine… ended up admitting two to nephrology…
 
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Tenk said:
You don’t want easy patients in residency. You want the hardest, craziest, non-sensical, dizzy, fatigued, chest pain, altered mental status, 80 year old, pregnant, male, unicorn you can find. You’re learning on someone else’s malpractice so don’t skimp on the hard ****.
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I agree with this but I think it all goes out the window when you’re in some off service rotation that has questionable relation to your field.
 
RustedFox said:
Yeah, I'm not clear on what rokshana meant, either.
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I think the point being made is that EM residents at his/her hospital had easier workloads on off-service rotations. N = 1, but my off-service experiences, especially in the ICUs, were not chill. My classmates and I were picking up the same patient volume and complexity as the other services' residents. Our seniors had q3 24s like theirs. We generally did more procedures as well (except on SICU for obvious reasons). And on MICU specifically it would be just EM folks and the MICU fellow covering during IM conference.
 
rokshana said:
Remember this when advising the EM resident when they are off service …where I did residency the EM residents had the whole day on Wednesdays for their diadactics…but of course never attending any of the IM one… and generally had lower pt load with the easier pts in the icu… and someone else had to take their pts on their “lecture” days…sometime you get what you give…
My goal on that 4 week rotation was to get my required Pap smears and not admit anyone to medicine… ended up admitting two to nephrology…
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I agree if your point is that we shouldn't expect FM/IM to be excited about the ED if we can't be equally excited during our medicine ward months. Touché. However, I really don't understand your point about protected didactic hours? (Every residency has them.) I also find your ICU experience with EM residents to be very unusual. ICU is a heavily focused/desired rotation for us as it deals with critical care medicine and provides a plethora of procedures. (Hence, why we do 3-5 of them.) The only exception might be the PICU, but for different reasons. I don't remember any difference in patient load from my IM colleagues in residency. In fact, the only difference I remember is that I did the majority of procedures because they didn't want to do them which was perfectly fine with me. The only exceptions being the pulm/cc fellows.

You sure you did Paps in the ED? I've never even heard of someone doing a Pap smear in the emergency department much less seen one. We don't even stock that stuff for our OB/GYN consults.
 
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Well I guess now we know why off-service residents are so slow in the ED--in addition to working up the CC, they're also providing comprehensive cancer screening.

(@rokshana, this is just a pet peeve for many of us, referring to pelvic exams as pap smears. It's annoying when nurses and patients do it, but it's inexcusable for physicians. We're not checking for cervical cancer, we're checking for PID)

I think most of us on here are attendings, right? This issue seems more like one of those petty things that residents get all peeved about but is inconsequential. Frankly, I think if it matters at all what off service residents are doing then the program is staffing wrong (although if they're cherry picking procedures, that's f'd up and needs to be addressed). Imho, they should be scheduled as extra help rather than essential.
 
turkeyjerky said:
Well I guess now we know why off-service residents are so slow in the ED--in addition to working up the CC, they're also providing comprehensive cancer screening.

(@rokshana, this is just a pet peeve for many of us, referring to pelvic exams as pap smears. It's annoying when nurses and patients do it, but it's inexcusable for physicians. We're not checking for cervical cancer, we're checking for PID)

I think most of us on here are attendings, right? This issue seems more like one of those petty things that residents get all peeved about but is inconsequential. Frankly, I think if it matters at all what off service residents are doing then the program is staffing wrong (although if they're cherry picking procedures, that's f'd up and needs to be addressed). Imho, they should be scheduled as extra help rather than essential.
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Eh… wasn’t something I wanted to do or frankly needed to do…but noted to not use that term.

Maybe the EM program where I trained for medicine was good at protecting their residents…they had all of Wednesdays off because the program there scheduled all of the lecture on that day… and they certainly didn’t come back once lectures were done… and they still had their 1in 7 off…so basically they got 2 days off a week during their rotations. Some would come in early to touch base on their patients and give the covering resident information for rounds… but wasn’t the norm.
But yes, my point was of you expect off service rotators to be excited and invested… then when y’all are off service, you need to be the same.
 
Groove said:
I agree if your point is that we shouldn't expect FM/IM to be excited about the ED if we can't be equally excited during our medicine ward months. Touché. However, I really don't understand your point about protected didactic hours? (Every residency has them.) I also find your ICU experience with EM residents to be very unusual. ICU is a heavily focused/desired rotation for us as it deals with critical care medicine and provides a plethora of procedures. (Hence, why we do 3-5 of them.) The only exception might be the PICU, but for different reasons. I don't remember any difference in patient load from my IM colleagues in residency. In fact, the only difference I remember is that I did the majority of procedures because they didn't want to do them which was perfectly fine with me. The only exceptions being the pulm/cc fellows.

You sure you did Paps in the ED? I've never even heard of someone doing a Pap smear in the emergency department much less seen one. We don't even stock that stuff for our OB/GYN consults.
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I didn’t turn over my patients to the other residents when i went to noon conference, but they weren’t required to manage their pts on their didactic day.
 
Massive difference from my ED rotations (as an FM resident) where we often cherrypicked the interesting cases as much as possible and got hands on with most traumas.
 
HemeOncHopeful19 said:
I agree with this but I think it all goes out the window when you’re in some off service rotation that has questionable relation to your field.
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Literally everything in medicine relates to EM. From being an embryo to dying at 105, we see it all, we treat it all.
 
I love how this thread started with a fellow EM colleague asking his own on how to deal with off service rotators (in the EM forum mind you....) and the IM attendings feel the need to rush to the rescue of these nameless FM/IM rotators while criticizing EM rotators in the process. My eyes rolled so much catching back up in here that I felt like I was having an oculogyric crisis. Talk about a thread derail.
 
Groove said:
I love how this thread started with a fellow EM colleague asking his own on how to deal with off service rotators (in the EM forum mind you....) and the IM attendings feel the need to rush to the rescue of these nameless FM/IM rotators while criticizing EM rotators in the process. My eyes rolled so much catching back up in here that I felt like I was having an oculogyric crisis. Talk about a thread derail.
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If you're unhappy with certain posts, you can always report them.

I'm not saying this to be flippant, we often do take action when people stir up trouble in other specialties forums.
 
VA Hopeful Dr said:
If you're unhappy with certain posts, you can always report them.

I'm not saying this to be flippant, we often do take action when people stir up trouble in other specialties forums.
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I'm not one of those forum cancel culture types. It would take a really egregious post to make me report it for anything. Although I don't like/agree with some of the posts in here, there's nothing remotely report worthy about them. After all, it's the bickering on SDN that makes reading the forum so much fun. Imagine if we always agreed on everything in here? Talk about boring. Plus, I like rokshana. I'm just snarky this morning. I'm only half way through my coffee.
 
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Groove said:
I'm not one of those forum cancel culture types. It would take a really egregious post to make me report it for anything. Although I don't like/agree with some of the posts in here, there's nothing remotely report worthy about them. After all, it's the bickering on SDN that makes reading the forum so much fun. Imagine if we always agreed on everything in here? Talk about boring. Plus, I like rokshana. I'm just snarky this morning. I'm only half way through my coffee.
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Heh, fair enough.

FWIW to join the anesthesia private forum you have to be an ASA member. Everyone here up for paying dues to ACEP to get a private forum like they have?
 
VA Hopeful Dr said:
Heh, fair enough.

FWIW to join the anesthesia private forum you have to be an ASA member. Everyone here up for paying dues to ACEP to get a private forum like they have?
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I think they just use that to vet people. I doubt you'd get 100% EM attendings on the ACEP train though you could probably get 90% if it was ACEP and/or AAEM.
 
rokshana said:
Remember this when advising the EM resident when they are off service …where I did residency the EM residents had the whole day on Wednesdays for their diadactics…but of course never attending any of the IM one… and generally had lower pt load with the easier pts in the icu… and someone else had to take their pts on their “lecture” days…sometime you get what you give…
My goal on that 4 week rotation was to get my required Pelvic exams ( which I never did again)and not admit anyone to medicine… ended up admitting two to nephrology…
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Ummm... The EM residents are attending their conferences on Wednesdays (not going on vacation)... Why would they then attend both IM and EM conferences?

As for lower patient load and easier patients in the ICU... That's a good one. EM off-service residents have the exact same patient loads when rotating in EM or ICU... As for not admitting anyone to medicine, this shows that you really slacked off in your EM rotation.
 
WilcoWorld said:
This is an interesting take. One I'm sympathetic to, and I think it helps clarify the question.

Should I make off-service rotators see patients they don't want to in the ED?

If your goal is to give the best patient care - hell no.
If your goal is to serve their education - depends on the patient.
If your goal is to teach the senior EM resident how to run an ED - maybe.
If your goal is to show them what working in the ED is like - yes, and better make 'em interpret an ECG while they're arguing with Radiology to do a CT that you don't really think is EMERGENTLY indicated, but you need to get to admit this patient and possibly will (in some way) serve the patient.

If your goal is to be fair - let me tell you this now, Medicine isn't fair.
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At my residency we were allowed to in-house moonlight picking up unfilled “off service” shifts .. my nocturnal self would pick up as many of the overnights as possible .. I could see the visible relief on the PGY2’s face when they got an EM PGY-3 instead of a psych intern LOL
That said, at least at my program we were expected to try as hard or harder on our off service rotations, especially ICU. On didactic day we’d come in early because we had to have our notes done by 0700 and report back immediately after conference. In my experience poor effort is more common in off-service ER rotators than in off-service EM residents … but I’m sure there’s plenty of both. Where I am now (no EM residency) the rotators almost never care, and we just send them home so we can do our work 🤷🏻‍♀️
 
Eh the private forums are nothing special like you'd think. I think it was originally made to keep crnas out and to talk politics. Mostly more sensitive cases or more detailed financial information. It's not meant to keep out other physicians as medical students and residents are welcome.
 
EthylMethylMan said:
I think the point being made is that EM residents at his/her hospital had easier workloads on off-service rotations. N = 1, but my off-service experiences, especially in the ICUs, were not chill. My classmates and I were picking up the same patient volume and complexity as the other services' residents. Our seniors had q3 24s like theirs. We generally did more procedures as well (except on SICU for obvious reasons). And on MICU specifically it would be just EM folks and the MICU fellow covering during IM conference.
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Yeah where I trained EM residents run whatever off service they are on. I think the only other rotation where other residents work as hard was probably Trauma/SICU because the surgery residents were great. But certainly we were known as the hardest workers in the hospital and I think that’s not uncommon
 
Angry Birds said:
Ummm... The EM residents are attending their conferences on Wednesdays (not going on vacation)... Why would they then attend both IM and EM conferences?

As for lower patient load and easier patients in the ICU... That's a good one. EM off-service residents have the exact same patient loads when rotating in EM or ICU... As for not admitting anyone to medicine, this shows that you really slacked off in your EM rotation.
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Oh i did! Never wanted to do the EM rotation…so i stayed out of the way and stayed in the D pod.
And not where I trained…they were treated like all the other off service rotators…we had psych residents rotate as well and they had lighter loads and easier pts as well.
And they should have attended the IM conference and not the EM ones…they were on an IM rotation…I went to the conferences of whatever rotation I was on as was required.
Again, I applaud the EM leadership… they protected their residents…to not have to manage their pts during lectures… it didn’t give them much good will amongst the other residents though…on and off service rotators alike.
 
Groove said:
I love how this thread started with a fellow EM colleague asking his own on how to deal with off service rotators (in the EM forum mind you....) and the IM attendings feel the need to rush to the rescue of these nameless FM/IM rotators while criticizing EM rotators in the process. My eyes rolled so much catching back up in here that I felt like I was having an oculogyric crisis. Talk about a thread derail.
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Because EM residents are the best residents where ever they rotate?
If an echo chamber is what you want…so be it.
 
rokshana said:
Oh i did! Never wanted to do the EM rotation…so i stayed out of the way and stayed in the D pod.
And not where I trained…they were treated like all the other off service rotators…we had psych residents rotate as well and they had lighter loads and easier pts as well.
And they should have attended the IM conference and not the EM ones…they were on an IM rotation…I went to the conferences of whatever rotation I was on as was required.
Again, I applaud the EM leadership… they protected their residents…to not have to manage their pts during lectures… it didn’t give them much good will amongst the other residents though…on and off service rotators alike.
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I think you like many others don’t understand how our specialty works and the different mindset it takes to be an EP. You work harder than most when you are on, and when you are off you are off.

Your general conference requirements are specific to your specialty. I don’t think it’s that high yield to go to another specialty’s conference. We needed to learn to think like an EP, not like an internist. It’s also not high yield to do a medicine floor month during an ED residency, which is why most have abandoned it.
 
rokshana said:
Because EM residents are the best residents where ever they rotate?
If an echo chamber is what you want…so be it.
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Oh, good grief. It wasn't a thread to dump on off service rotators. The OP simply wanted advice from FELLOW EM DOCS on how to deal with lazy off service rotators. How that turned into a DEFCON SDN alert for you , I have no idea... Why on earth are you sticking around to argue so much and defend your experience with what you perceived as "overly coddled" EM residents? Ok, we get it....you weren't that impressed with them. Who cares? It has zero to do with the original topic. Start a new thread if you want to argue about EM vs IM residents on off service rotations.
 
So this is a bit concerning/disappointing to me, though I guess not surprising. I‘m not a doc so I don’t have to deal with managing an ED like you all do, but I just spent the previous 6 years working in rural critcal access shops where most, if not all, of the ED coverage is by FM docs (and a few other random specialties and even two that only did 1 year of residency)

The differences in mgmt and flow between the two EM guys and everyone else was striking.

I’d like to think if an FM resident thinks they’ll want to work in an ED in the future they’d put more effort into the rotation. However it seemed like quite a few of them made the decision later on.

Given that, and as noted above how EM touches every other specialty, seems like there would definitely be value in having off service residents step up. Though that should be a system level fix, not on you all individually to deal with.
 
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Overhead in the ED:

"It's bullcrap that I have to spend 90% of my time seeing patients that aren't sick. Wait...Look! Can you believe that guy? All he does is go see patients that aren't sick and there's none left for me."
 
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