Residency Curricula

[Coleman]

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It seems to be the "mantra" of this board that all residencies give you an equivocal education because of the strict requirements set out by the RRC. I've always accepted these comments for no other reason than I didn't know better in my 1st and 2nd years.

As my 3rd year is coming to an end, I have realized that this mantra may not mean what I took it to mean. I would say that if someone is worried about a program not being on par with every other program, they can feel comfortable that the RRC requirements are met and that their education will be sufficient.

However, the RRC only lays down a minimum requirement so-to-speak. Most programs meet this minimum and then continue to diversify themselves from other programs after that.

In comparing curricula between programs, I have found a huge variation, not only in experience but in other lifestyle factors such as call months. I know of one program with 3 months of trauma plus one month each in CCU, ICU, SICU, Medicine, and General Surg. It is not stated outright, but I am assuming these all contain call.

This is compared to another program with NO trauma, 2 months CCU, and no Medicine or G. Surg month.

This is a huge difference not only in lifestyle during residency, but in experience and training as well. As much as I DESPISE call (working a full day, going on call, then rounding the next morning putting in ~ 30 hours), I have found that that is where experience is gained. Rounding on established patients is not the learning that call is.

Just curious as to what you all think about this. I have thoroughly complicated my decision for the match with this. I am looking for a great education and experience, but I also am not going into EM to live the life of a surgeon intern for my residency.

 

[Scrubbs]

Coleman...

You're right that there are very different ways that residency programs fulfill their requirements. The old addage of EM seems to be that in order to learn about surgical issues, one needs to be a surgeon for a month. However, some programs are starting to think - and I definately agree - that Surgical EMERGENCIES are different from surgical floor patients. Applies to most specialties as well. What we need to know as Emergency Physicians is how to diagnose, stabilize, and treat emergencies. Not how to order TPN and write daily progress notes. Therefore, a lot of programs are moving away from scutty floor months, and adding more EM and ICU months.

I don't know which way is better, and I think that both types of programs train good doctors. However, I opted for a program with NO floor months. We have 6 ICU months instead... which is on the top end for the programs that I looked at. Basically, the thought is that we learn Emergency Medicine in the Emergency Department.

As for the differences in trauma months (my program doesn't have any dedicated), its program dependent. Some have it set up where the only time you're running traumas is when you are on trauma month. Others have it so that the 2nd/3rd year in the dept run all traumas. I think that not having a dedicated trauma month means one less SURGICAL month.

The RRC requirements make sure that EM residents all get a good number of procedures, see varied patients, and know how to do the same stuff. How the programs go about accomplishing this is up to them. As you go through your interviews, make sure to ask residents who does what... who manages trauma airway, how many chest tubes have you done, have you ever done/seen an ED thoracotomy, etc. This is where you start to see differences in programs beyond the basic RRC requirements.

 

[tonem]

Coleman,

I think you hit the nail on the head. That's why the other "mantra" on these boards is that the interview trial is a critical part of finding a program where you feel like you will be the happiest for the 3 or 4 years you'll be there.

I agree with Scrubs in that a lot of programs I visited either were pulling residents out of "scut" rotations in surgery or arranging more meaningful experiences such as handling in-house/ED consults for the surgical teams.

 

[DrQuinn]

Good point Coleman...

Thinking back on my interviews, I did notice a big difference in Trauma experience. Some had NO trauma seen in the ED, but excellent trauma rotations (2-3) (such as Univ of MD with Shock/Truama), where as some only had 1 month of dedicated trauma surgery with trauam being run by EM residents...

I think the general philosophy that the PDs talked to me about is that what you said... "Emergency Medicine is best learned in the ED." I think the general scut ward floor months are being weeded out (that being said, I have my third rotation as a PGY-1 as "ward medicine").

From what I was told by EM attendings in and out of academia, is that the RRC actually ahs very strict guidelines for EM, and enforces them more than many other residencies, and this keeps EM in tip top shape.

Hearsay? Spin doctoring? Maybe. But we'll never know.

As long as I pass my boards and am ABEM certified, I think my residency will have taught me enough. Of course, if I fail, then I'll be pissssssssssssssssssssed.
Q

 

[Nof55]

Coleman,
Like everyone else said, this really is the purpose of your interview trail. You had to go and ask the residents. That being said I did look for some particular things:

1. Who runs trauma - even though this is cookbook medicine I wanted to get comfortable with this, and some good procedure experience.
2. Are you complying with U/S recommendations from RRC - this is a personal choice, some people do not feel this is important, I felt this was a good indicator of who was trying to push the envelope of training for their residents.
3. When and how am I trained to intubate - being trained to intubate emergently is very different than the more relaxed pace in anesthesia, though you have to walk before you run.
4. What are the ortho rotations like, do they cover hand - am I in the OR holding up legs or am I in the ED and consulting in the hospital. Do I have to do a plastics rotation to get hand experience.
5. What about Peds, Tox and Geriatrics?
6.Where do I learn how to manage an ED, preparation for solo coverage?
7. MOST IMPORTANT - HOW GOOD ARE THE RESIDENTS, WHAT IS A TYPICAL DAY LIKE.

These are just a few things to think about. You will get your own list. Above all try to spend some time in the department before/after your interview. Nof55

 

[Coleman]

Hey all, thanks for the response:

Scrubbs: I totally agree with you about floor work. It is, for the most point, a waste of time. Your program, I know for a fact, is great and ideal in my opinion, with so many ICU months and experiece.

In regards to your trauma exposure, that is interesting how your program runs their traumas and would be misleading to outsiders who are not aware of it, they would think, as I did, that you had no experience with trauma cases.


Nof55: Thanks for the questions, you brought up a lot of great points. One thing I've found with my 3rd year rotations is the amount of variability at my own institution among various rotations. Depending on where you rotate in surgery, your experience here ranges from 1st assistant to scrubbed in observer whose gloves never get dirty.

Thanks all.

 

[Scrubbs]

Not sure if this is true of ALL programs, but on the residency trail I found that if a program didn't have a dedicated trauma month, they are generally involved in traumas on all ED months. Trauma is an important and necessary part of our training, so they have to have it somewhere. Many programs have the EM residents rotate on a schedule with the surgery folks as to who "runs" the trauma. Everyone is involved in all traumas, but everyday it switches b/w EM and surgery for who runs them.

I agree with Nof55's question list... others that I'd add:

1. Who does trauma intubations? Does anesthesia show up?
2. What are shift changes like? Do you typically sign out patients or stay to clean up all messes?
3. For U/S, do you need to get a confirmatory study by rads?
4. What non-clinical responsibilities do residents have? (supervising, lectures, etc)
5. What is the research requirement?

There is a really good list of questions on one of the EM sites... I think its on EMRA.

 

[SHOX]

I actually disagree with the pervailing philosophy in this trend with regard to off-service rotations.

Granted you want to be able to master the ABC's and stabilize but you need to anticipate the next few steps in patient care especially now with the crisis of ED crowding and patients sitting in the ED for 24 hours waiting for a bed.

Working in the ED you do get to see and do lots of things however you also get taught a very uni-demensional approach to patient care. As a jack of all trades, who better to learn newborn/ pediatric intubation from than the neonatologist (especially since these are rare procedures in most EDs), who better to learn pathophysiology of disease and where in the hospital to admit a patient to (ICU, SDU and Floors) than from the IM guys. Working with all the different experts in their respective fields really gives you another perspective on how to approach patients and you can then be multi-demensional as you find your own style. This all really depends on how good your off-service rotations are and this is very institution dependent.