Residencies that are almost unopposed

[docman85]

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So I have been researching EM programs for a while now and really like the idea of having as few residencies at the hospital i choose as possible. The only one I have really found in Christus Spohn, which only has EM and Family. Are there any other programs out there like this? Also is this a good idea, in that I feel like I will get more time to learn things without having to consult them out or am I looking at this wrong?!?!

 

[VienneseWaltz]

Your word choice is interesting. I didn't think of my residency as being in opposition to other residency programs. Training in a place with many other strong programs keeps you on your toes, and I have found that the residents at my hospital were often willing to do a little teaching in the hopes that they might not get called the next time. However, I have heard the argument that limited consultation in theory allows the EM residents to do more (ophtho, reductions, plastics closures, etc), although sometimes these cases just get transferred to the hospitals with all the fancy specialist services...

 

[gutonc]

Your word choice is interesting. I didn't think of my residency as being in opposition to other residency programs.

It's a term that's frequently used in regards to FM programs. For FM training I think it makes a lot of sense (since FM programs in large hospitals with every other specialty usually just become the dumping ground for uninsured patients) but not so much for EM for the reasons you mentioned.

 

[GeneralVeers]

So I have been researching EM programs for a while now and really like the idea of having as few residencies at the hospital i choose as possible. The only one I have really found in Christus Spohn, which only has EM and Family. Are there any other programs out there like this? Also is this a good idea, in that I feel like I will get more time to learn things without having to consult them out or am I looking at this wrong?!?!

The only place I really noticed a benefit was on trauma. You get to do all the procedures and manage all of the patients. This is more work in the end, and the trauma rotation is quite taxing, however you don't have to fight with surgical residents for procedures.

 

[snoopy85k]

There is also the aspect that you will spend about 1/3 of your residency on off-service rotations. While its nice to have first dibs on things, its also important that those off service rotations are of great value and have great teaching. This is not to say that it requires a residency program to have great teaching or that you will actually get great teaching off-service in places with other residencies, but it is something to consider. As a student, I like having the perspective of the attending(s) and resident(s) on each service because I feel that it makes my education more well rounded as differing views/approaches are debated and instituted.

 

[Nervous Ned]

So I have been researching EM programs for a while now and really like the idea of having as few residencies at the hospital i choose as possible. The only one I have really found in Christus Spohn, which only has EM and Family. Are there any other programs out there like this? Also is this a good idea, in that I feel like I will get more time to learn things without having to consult them out or am I looking at this wrong?!?!

I think the ideal scenario is to work in multiple practice settings. In the community hospital where we rotate, we don't have nearly as much backup as we do at UMass. I learned a lot about being relatively self-sufficient as an EP on that rotation. On the other hand, rotating only at a community hospital would not give you as much opportunity to learn from your consultants. They are experts at what they do, and they can teach you a lot about their field. So IMO you really need to be exposed to both types of practice settings during residency in order to best develop your skills as an EP.

 

[EM_Rebuilder]

So I have been researching EM programs for a while now and really like the idea of having as few residencies at the hospital i choose as possible. The only one I have really found in Christus Spohn, which only has EM and Family. Are there any other programs out there like this? Also is this a good idea, in that I feel like I will get more time to learn things without having to consult them out or am I looking at this wrong?!?!

It seems like its already been mentioned, but I don't know what so many students get into this idea that 'unopposed residencies are better'... For EM, I certainly do not think this is the case.

If you are unopposed, that means you do not have specialist, or only private specialist, which are NOT going to show up to the ED at 2AM (or probably anytime for that matter) and you are going to transfer the patient to the tertiary care center....

I trained at a program with everything. My experience was that we took care of everything that came to the doors, plus all the transfers for the 'specialists' care. We only shipped burns as we did not have a burn center... however, any burns within 50 or so miles came to us first as we had to fix wing them elsewhere...

I moonlit at many places WITHOUT those specialist where transfers were the name of the game. When you are at 'the big center', I think you have MUCH more ability to 'play' and experience many procedures. Rather it be with your attendings, or with the fellows/residents from the other services you call. Some of that stuff you probably never will do in the real private world anyhow... I've drained priapisms before, did scalene blocks with nerve stimulators, etc. There is no way I would stick a needle in that part of the body if I were in a private hospital, with or without a private urologist on call... maybe I am just a wuss?

I work now as an attending at a Level 1 / tertiary care academic center without an emergency medicine program. Its nice because there are many things I can go ahead and do right before calling the fellows/residents, or I even go help them out sometimes. Its also nice that, like in residency, I can have cards at the bedside in 5 minutes to look at the 'iffy' EKG with me...if you were at an 'unopposed' program, you would just ship them or decide to give the lytics yourself. Some may say its hand holding, but I dont think it is...its about learning and having direct contact with what ENT likes antibiotic wise for deep space abscess, or what films ortho likes to have before being called... I think part of our job is to 'be inside the head' of the consult and having some concept of how they go about treating XYZ. I think thats hard to get without daily bedside interactions with those consults. I learn still today from some of my interactions with other service residents/fellows and occasionally their attendings..

 

[deleted65604]

I'm an advocate of heavy training at a place (at least for a significant part of your residency) where the ER attendings don'g just act as the consult fairy and admit to everyone without a work-up. In my residency, the attendings would consult ortho on every fracture, or even occult fracture. Every chest pain got admitted to our own obs unit which gave our department its own extra revenue source. Every neurologic deficit had a neurology consult, every tooth abscess got a dental consult. Not good for learning.

In mega-tertiary centers, primarily run by residents, this is the way things need to be done for the sake of safety. Emergent things are trouble-shot by the residents during the night, and post-poned until the real doctors show up in the morning for a few hours and do life-saving diagnostics, and procedures.

 

[docman85]

Thanks everyone for the responses, and sorry if I came across as though I think one kind of program is superior to another. The above posts gave me something to think about when applying this next year. My ultimate goal is to practice at a community hospital for quite a while and then return to academics towards the end of my career and from what y'all have said it seems that most programs would prepare me for the community hospitals. Thanks again

 

[deleted109597]

If you are unopposed, that means you do not have specialist, or only private specialist, which are NOT going to show up to the ED at 2AM (or probably anytime for that matter) and you are going to transfer the patient to the tertiary care center....

Minor bone to pick. Just because you don't have other residencies doesn't mean you're transferring patients. It just means that those patients are cared for by private docs. For emergent operations, they'll come in. For STEMI, they'll come in. For stroke, they don't, and you're left making the decision to give/withhold lytics. Neurologists just don't make enough to bother coming in apparently.

As far as "which is better" I don't know the answer. My best guess would be In-n-Out, followed by USC/LA County. I only say that because I hear the guys that teach there, and they were light years ahead of where I trained.

 

[pinipig523]

I think that being in a residency with a strong EM program which has admission privileges over most (if not all) services has pros and cons. Pros would include less consult calls, more throughput, ability to really work on patients how YOU see fit.

Cons would include a tainted view of how "real" ER works in the community setting.

 

[GeneralVeers]

Minor bone to pick. Just because you don't have other residencies doesn't mean you're transferring patients. It just means that those patients are cared for by private docs. For emergent operations, they'll come in. For STEMI, they'll come in. For stroke, they don't, and you're left making the decision to give/withhold lytics. Neurologists just don't make enough to bother coming in apparently.

As far as "which is better" I don't know the answer. My best guess would be In-n-Out, followed by USC/LA County. I only say that because I hear the guys that teach there, and they were light years ahead of where I trained.

You are correct. The Level 2 trauma center we are referring to had all the specialists: In house surgery 24/7, Neurosurgery, ENT, OMF, Plastics, and Ortho. We only transferred out patients needing very specialized care like severe burns, or acetabular fractures.

In fact, I'd say the 1:1 interaction you get with specialist attendings was often more useful than interacting with grumpy surgical residents.

 

[Venko]

I think that being in a residency with a strong EM program which has admission privileges over most (if not all) services has pros and cons. Pros would include less consult calls, more throughput, ability to really work on patients how YOU see fit.

Cons would include a tainted view of how "real" ER works in the community setting.

It really isn't about how anyone person sees fit to manage anything but rather what is the best thing for the patient given the resources and staffing available at the location. To act on an island is a lonely way to be and even in the community, they work as a team.

My point with this distinction is "unopposed" and "how I see fit" etc lead to a contentious relationship with the hospital and can negatively impact a patient's care; everything is a team approach and should be so. Bring a specialist in to the ED if it is what is best and learn from them about how you can do better for the next patient. Admit to the right service with the RIGHT management for the patient...

 

[gman33]

Currently trying to pick a residency program.
It seems like a good way to go is a place that has multiple sites with different practice environments. Learn from the specialists at a big academic place and learn how to manage more on your own at a community site.

 

[turkeyjerky]

Currently trying to pick a residency program.
It seems like a good way to go is a place that has multiple sites with different practice environments. Learn from the specialists at a big academic place and learn how to manage more on your own at a community site.

Yeah, but then you spend your entire first year trying to learn the different systems and only later on are able to focus on learning the medicine. Not to mention all the (wasted) time spent commuting to the various hospitals.

 

[gman33]

Yeah, but then you spend your entire first year trying to learn the different systems and only later on are able to focus on learning the medicine. Not to mention all the (wasted) time spent commuting to the various hospitals.

One place I'm looking at, first year all at academic place, second year at 2 community sites mainly. Commute time would be the same to all sites for me.

 

[turkeyjerky]

So you spend both first and second year learning the different systems? JK, kinda, what program is that?

 

[deleted65604]

Yeah, but then you spend your entire first year trying to learn the different systems and only later on are able to focus on learning the medicine.

If you can't "learn the different systems" in a couple of days, then you are not cut out to be in medicine. What is there to learn? "I need a particular specialist, who should I call?" you ask the tech, and they tell you. "I need to admit to the hospital, their primary is this person, who do I call?" In a few seconds, the phone is ringing and your admitting doc is on the line.

 

[deleted65604]

In fact, I'd say the 1:1 interaction you get with specialist attendings was often more useful than interacting with grumpy surgical residents.

Absolutely correct. Surgical and subspecialist residents are almost universally toxic. The most unprofessional interactions I ever experienced was with fellow residents on other services trying to be pricks and block admissions.

 

[deleted65604]

I think that being in a residency with a strong EM program which has admission privileges over most (if not all) services has pros and cons.

How can an EM program have admission privileges over other services? What do you mean by that?

 

[deleted109597]

If you can't "learn the different systems" in a couple of days, then you are not cut out to be in medicine. What is there to learn? "I need a particular specialist, who should I call?" you ask the tech, and they tell you. "I need to admit to the hospital, their primary is this person, who do I call?" In a few seconds, the phone is ringing and your admitting doc is on the line.

Now, I agree that this is how it should be, but at many teaching hospitals. the residents are the secretaries. Also, sometimes there are arbitrary confusing systems for admission for patients without a primary (or without a local primary). We had a system where it went IM, then FM, then the private hospitalists x3, then back to IM, then FM. It was ridiculous, and if you didn't have the sheet in front of you they wouldn't talk to you.
Asking someone else who to call was often met with blank stares. Heaven forbid you actually ask the secretary to call someone for you.
It's better at the private places.

 

[VienneseWaltz]

Yeah, but then you spend your entire first year trying to learn the different systems and only later on are able to focus on learning the medicine. Not to mention all the (wasted) time spent commuting to the various hospitals.

"Learning the system" even at several different centers should not dominate the first year over clinical knowledge, and even at a single hospital interns rotate through many different services with their own "systems" to learn; emergency medicine residents generally adapt quickly anyway. Exposure to a variety of practice settings has far more advantages than disadvantages.

 

[Venko]

"Learning the system" even at several different centers should not dominate the first year over clinical knowledge, and even at a single hospital interns rotate through many different services with their own "systems" to learn; emergency medicine residents generally adapt quickly anyway. Exposure to a variety of practice settings has far more advantages than disadvantages.

I don't know VW, of course there is a point when learning goes down from more systems. In the extreme, a new system each day would certainly not be a good learning situation. Furthermore, as an attending each new system I have learned takes a few months to get under my belt from the EMR, to the method for admission, to the culture and as an attending I don't have off-service rotations, and as much studying to do etc; furthermore, i work a more consistent shift load and receive more respect in the department.

I think as a resident especially intern when order entry and making phone calls can sometimes be the name of the game, the more systems to learn even three EMRs, nursing cultures, hospital admitting procedures, etc can be an overwhelming task when you only have 6-7 months of EM in the first year anyway.

Just my thoughts on this.

TL

 

[WilcoWorld]

I don't know VW, of course there is a point when learning goes down from more systems. In the extreme, a new system each day would certainly not be a good learning situation. Furthermore, as an attending each new system I have learned takes a few months to get under my belt from the EMR, to the method for admission, to the culture and as an attending I don't have off-service rotations, and as much studying to do etc; furthermore, i work a more consistent shift load and receive more respect in the department.

I think as a resident especially intern when order entry and making phone calls can sometimes be the name of the game, the more systems to learn even three EMRs, nursing cultures, hospital admitting procedures, etc can be an overwhelming task when you only have 6-7 months of EM in the first year anyway.

Just my thoughts on this.

TL

I agree with the above. Residency is for learning medicine. You can learn multiple systems once you already know the clinical material you're getting attending pay. However, if you find that the perfect fit for you is a program that rotates through 3 sites, I wouldn't let that one single fact dissuade you.

 

[Venko]

I agree with the above. Residency is for learning medicine. You can learn multiple systems once you already know the clinical material you're getting attending pay. However, if you find that the perfect fit for you is a program that rotates through 3 sites, I wouldn't let that one single fact dissuade you.

I agree, it shouldn't be a make or break but be only used as a consideration.

 

[VienneseWaltz]

I suppose it's specific to the program. If the orientation is adequate, the staff are supportive, and interns are at least somewhat protected, it makes a big difference versus a throw-the-baby-docs-in-and-see-whether-they-swim kind of environment. I think the advantages of different sites include the exposure to different admitting cultures, patient populations, specialty coverage, and practice environments.

My two cents--and I agree that this shouldn't be a deal-breaker or -maker.

 

[gutonc]

How can an EM program have admission privileges over other services? What do you mean by that?

At our institution, when the ED says the pt needs to be admitted (to IM, FM or Peds services), that's the end of the discussion. There's no "do you think s/he could be obs'd" or "she seems stable for discharge and we can see her in clinic tomorrow morning for follow-up." They're coming in because the ED has admission privileges on those services.

This is usually a good thing since it prevents residents trying to block soft (or not-so-soft) admits to avoid work, but occasionally results in admits where the wait for the van to take grandpa back to the SNF is longer than the time on the floor.

 

[UnderwaterDoc]

At our institution, when the ED says the pt needs to be admitted (to IM, FM or Peds services), that's the end of the discussion.

That's exactly how it works in our ED too, and it's great. You call, you say this patient needs to be admitted for XYZ, and you're done. Any push back and I say have your attending call my attending, hasn't happened yet.

 

[Nervous Ned]

That's exactly how it works in our ED too, and it's great. You call, you say this patient needs to be admitted for XYZ, and you're done. Any push back and I say have your attending call my attending, hasn't happened yet.

It's like that at UMass too for general medicine and subspecialties like cardiology. The cards fellows still argue sometimes, but ultimately they can't refuse an admission if we insist that they take it.

 

[Hamhock]

How can an EM program have admission privileges over other services? What do you mean by that?

Like others have said before:

Where I trained, this meant that once the ED attending decided on admission and the appropriate service, "official" discussion ended. A bed was processed and the admitting team had to respond within two hours to write admission orders or transfer orders (to another service).

The only way out was if the admitting service attending came to the ED (never saw it!) and discharged the patient.

However, it rarely came to this.

It was the responsibility of the EM attendings and senior residents to maintain a good relationship with the other departments and ensure patients were admitted to services that could provide best care.

This required selective consultation and discussion.

For potential applicants:

IMO, it is important identify programs that don't require you to spend hours "consulting" multiple specialties for the "right" to admit (and NEVER hearing from residents "this patient doesn't need to be admitted" vs. working in a place where the ED "rules" and the other specialties must "listen" (although this later option is the type of program in which I trained, it may not be the best, as the "best interests"of the patient are not always in mind and there is often very little learning off-service and from consultants in the ED).

With that said, I would still pick training in a program where the opinion of ED attendings is more important than an admitting "resident".

HH

 

[deleted65604]

Having worked at a place for three years where 2/4 of the hospitalists were truly pathologic, I think that getting push-back on admissions is necessary for good training. One of the hospitalists that I admitted to gave push-back on literally every patient I would try to admit. I hate his guts, but he taught me, and forced me to have my ducks in a row when I wanted to talk to him.

Sometimes your attending gets lazy and becomes the consult/admission fairy that waves their magic wand and makes patients disappear from the department fast. This is a wonderful wand to have indeed, but that wand doesn't exist in the real world. In the real world, you need to be able to concisely sell a patient in 20-30 seconds, painting a picture that screams need for admission. In the real world, there is an army of people in the hospital walking around with CMS rules about admittable diagnoses, reimbursement guidelines. Modern hospitalists are under the gun from administration to only admit reimbursable patients.

 

[UnderwaterDoc]

Having worked at a place for three years where 2/4 of the hospitalists were truly pathologic, I think that getting push-back on admissions is necessary for good training. One of the hospitalists that I admitted to gave push-back on literally every patient I would try to admit. I hate his guts, but he taught me, and forced me to have my ducks in a row when I wanted to talk to him.

Sometimes your attending gets lazy and becomes the consult/admission fairy that waves their magic wand and makes patients disappear from the department fast. This is a wonderful wand to have indeed, but that wand doesn't exist in the real world. In the real world, you need to be able to concisely sell a patient in 20-30 seconds, painting a picture that screams need for admission. In the real world, there is an army of people in the hospital walking around with CMS rules about admittable diagnoses, reimbursement guidelines. Modern hospitalists are under the gun from administration to only admit reimbursable patients.

You make a good point, and I wish that was possible at our institution, however we only talk to the residents at our shop, and I can count with one hand the times that I have called them and they actually make an intelligent argument against admission, hence the fact that they cannot refuse admissions streamlines the process tremendously.

 

[gutonc]

That's exactly how it works in our ED too, and it's great. You call, you say this patient needs to be admitted for XYZ, and you're done. Any push back and I say have your attending call my attending, hasn't happened yet.

I will say that one problem with this (at our institution anyway) is that the ED only has admitting privileges for IM, FM and Peds. So when a non-trauma patient should be admitted to a surgical service, that service can say, "we agree Mr. Jones needs to be admitted but not to our service, admit to medicine and we'll follow along." Follow along in these cases usually means "we'll write an initial consult not and occasionally answer pages from the medicine team about the patient."

 

[UnderwaterDoc]

I will say that one problem with this (at our institution anyway) is that the ED only has admitting privileges for IM, FM and Peds. So when a non-trauma patient should be admitted to a surgical service, that service can say, "we agree Mr. Jones needs to be admitted but not to our service, admit to medicine and we'll follow along." Follow along in these cases usually means "we'll write an initial consult not and occasionally answer pages from the medicine team about the patient."

This is also very true, admitting a patient to ortho or surgery is like trying to fit a clam into a piggybank. We almost had a small party when we got someone admitted to neurosurgery the other day.