Residency program deal-breakers

[winkleweizen]

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There are ways to get around it. Sometimes people pick up the tab (I.e. the PD, attendings or residents) or you can do some creative accounting by calling it a "catering fee" or having a price per person charged by the restaurant that includes booze. Of the 7 I've been on, only 2 have made us buy our own beer. Heck, 3 or 4 of them have been at breweries!

Lol, i think almost all of mine have been at breweries.

 

[e30ftw]

My only deal breaker so far is a 4 year program.

Other things that irk me about programs, but aren't necessarily deal breakers would be:
1) programs that don't tell applicants that alcohol won't be included at pre-interview dinner
2) programs that can't stay on schedule with their own interview schedule
3) programs that allow attendings to come to the pre-interview dinner and/or lunch the next day
4) interviewers who have obviously never looked at my file
5) residents at the program who seem ******ed
6) faculty who seem disinterested during the interview
7) residents who interview applicants and act like they have been attendings for 10 years
8) no SWAG: seriously, I paid $400 on plain tickets and I can't get a damn pen
9) residents at the program who look more exhausted than the neurosurgery residents
10) no breakfast provided at the interviews
11) faculty who seem like they hate their life: it shows during the interview

many experiences with all of the above last year, agree completely.

loved almost all the programs i went to, but was honestly surprised all things considered how many times these things happened.

 

[Glitterbox]

Don't do it during interviews. Ask it during the tour. Something like, is there a room where we can eat and still have a workstation?

Many places have their doctors in a small room that isn't "patient care" so they're safe to eat. As long as there's a door you're covered.


What did the residents who worked at your away do?

I didn't really see them eat. There was one super slow day where one went out to get lunch and ended up eating in the breakroom.

 

[Snelgrave]

How would you suggest trying to ascertain this while interviewing? I haven't been to a single program that doesn't claim to have a "really strong" peds experience that sees "really sick" kids. Anything more than pure number of shifts?

Does the hospital see enough kids to justify an separate pediatric EM area?

Does the hospital have a PICU or pediatric subspecialties? Are any of your faculty fellowship trained in pediatric EM? EMS or parents will not bring you the kids if your hospital can't handle them, and you would have to transfer them anyway.

If the above questions are "no" at your main training site, what is the off-service experience? I would argue that only one month of dedicated peds, even at a children's hospital, is not enough for a program claim they are "really strong" in peds.

 

[Rendar5]

Does the hospital see enough kids to justify an separate pediatric EM area?

Does the hospital have a PICU or pediatric subspecialties? Are any of your faculty fellowship trained in pediatric EM? EMS or parents will not bring you the kids if your hospital can't handle them, and you would have to transfer them anyway.

If the above questions are "no" at your main training site, what is the off-service experience? I would argue that only one month of dedicated peds, even at a children's hospital, is not enough for a program claim they are "really strong" in peds.

Peds EM month, PICU (only a 12-15 pt unit, but good pathology from an ER perspective), and random peds shifts throughout all 3 years is what made me feel comfortable with kids (and the peds ED was open for 18 hours a day, so overnights we saw kids in the main ED). It was something I looked for in a program because I'd always hear how everyone felt uncomfortable with kids as attendings

 

[Cerberus]

Peds EM month, PICU (only a 12-15 pt unit, but good pathology from an ER perspective), and random peds shifts throughout all 3 years is what made me feel comfortable with kids (and the peds ED was open for 18 hours a day, so overnights we saw kids in the main ED). It was something I looked for in a program because I'd always hear how everyone felt uncomfortable with kids as attendings

My program has a strong peds department. We are high volume. We only have peds EM trained attendings in the pedsER. I'm still pretty sure I'll never feel entirely comfortable with pediatrics. The problem is that it takes A LOT of sick peds patients to become really comfortable with them and no matter where you are, most kids will not be that sick.

 

[AmoryBlaine]

I really encourage med students to stay away from this "deal breaker" mentality.

Time and time again I hear students say things like:

"well they don't manage the airway in trauma!"
"I don't like the # of off service months."
"I'm not sure their u/s experience is strong."

In all honesty (not trying to flame) med students have no idea how to train a competent EM doc and listening to them agonize over things like u/s experience is just odd.

Trauma airway is not the hardest thing in your job, the hardest thing in your job is seeing 2.5 pts/hr for the rest of your life while not making many mistakes and keeping 2 pts/hr happy enough that they don't complain about you while simultaneously making all the RNs/techs think that you are a nice enough guy and not creating problems for your boss.

Med students tend to ask questions about the day to day experience of residency, they should ask more questions about what life is like for graduates.

There is a program close to me that has a great rep. Tons of crit care, tons of u/s, TONs of procedures, one of the most high acuity ERs I've ever heard of. Problem with it, at least from my standpoint, is that their grads tend towards these second tier jobs and many are unhappy with their jobs a year out.

I would rather someone got good career direction and counseling rather than an extra 5 trauma tubes.

 

[Rendar5]

My program has a strong peds department. We are high volume. We only have peds EM trained attendings in the pedsER. I'm still pretty sure I'll never feel entirely comfortable with pediatrics. The problem is that it takes A LOT of sick peds patients to become really comfortable with them and no matter where you are, most kids will not be that sick.

to be fair, you're right that most kids in the community aren't severely sick, and that no one is emotionally comfortable with a truly sick kid except for maybe a pediatric intensivist. but except for the congenital heart kids (which still scare me), I'm happy to see each and every kid that walks through those doors, and feel comfortable in my training and skills. There are so many peds EDs out there nowadays though, that unless having a decent familiarity and comfort level with kids is important to you (as it was me), most people are comfortable finding jobs with minimal peds contacts.

 

[Cerberus]

to be fair, you're right that most kids in the community aren't severely sick, and that no one is emotionally comfortable with a truly sick kid except for maybe a pediatric intensivist. but except for the congenital heart kids (which still scare me), I'm happy to see each and every kid that walks through those doors, and feel comfortable in my training and skills. There are so many peds EDs out there nowadays though, that unless having a decent familiarity and comfort level with kids is important to you (as it was me), most people are comfortable finding jobs with minimal peds contacts.

I feel comfortable with 98% of peds. It's the 2% (particularly congenital cardiac kids) that scare the bejeesus out of me. I can run multiple sick sick adult resuscitations at a time and feel completely comfortable, but give me one septic baby with a pacemaker that isn't accounting for septic shock, and it's a ****storm (a case I recently had, and did fine with aside from soiling my underpants). I think peds is an important aspect of residency, I feel well trained in it, but still hope that following residency I never have to see another peds case for the rest of my life.

 

[deleted109597]

If the above questions are "no" at your main training site, what is the off-service experience? I would argue that only one month of dedicated peds, even at a children's hospital, is not enough for a program claim they are "really strong" in peds.

Well, the RRC requires 16% of clinical visits, or 4 entire months of residency be devoted to peds, with at least 50% in the emergency setting.

This of course changes in July, when that number goes to 20%, or 5 months and 50%.

So if there's a place saying they've got one month of peds, they aren't meeting the minimum.

 

[Glitterbox]

I really encourage med students to stay away from this "deal breaker" mentality.

Time and time again I hear students say things like:

"well they don't manage the airway in trauma!"
"I don't like the # of off service months."
"I'm not sure their u/s experience is strong."

In all honesty (not trying to flame) med students have no idea how to train a competent EM doc and listening to them agonize over things like u/s experience is just odd.

Trauma airway is not the hardest thing in your job, the hardest thing in your job is seeing 2.5 pts/hr for the rest of your life while not making many mistakes and keeping 2 pts/hr happy enough that they don't complain about you while simultaneously making all the RNs/techs think that you are a nice enough guy and not creating problems for your boss.

Med students tend to ask questions about the day to day experience of residency, they should ask more questions about what life is like for graduates.

There is a program close to me that has a great rep. Tons of crit care, tons of u/s, TONs of procedures, one of the most high acuity ERs I've ever heard of. Problem with it, at least from my standpoint, is that their grads tend towards these second tier jobs and many are unhappy with their jobs a year out.

I would rather someone got good career direction and counseling rather than an extra 5 trauma tubes.

What are second-tier jobs?

 

[la gringa]

Trauma airway is not the hardest thing in your job, the hardest thing in your job is seeing 2.5 pts/hr for the rest of your life while not making many mistakes and keeping 2 pts/hr happy enough that they don't complain about you while simultaneously making all the RNs/techs think that you are a nice enough guy and not creating problems for your boss.

agree 100%

i would add: if you're a woman - being a nice enough gal so the RN's/techs don't think your're a bitch but not too nice so they think you're a pushover. even better, find a spot where the experienced and noncatty nurses want to be and WORK THERE.

i have done exactly ZERO "trauma airways" since residency (over 3 yrs now).... because guess what? most of us will not work in a level 1 trauma center!! the "trauma" you will see is so mind numblingly painful that you will with you never saw a c-collar again in your life (at least that's my perspective)

 

[AmoryBlaine]

What are second-tier jobs?

There are a lot of terrible jobs at community hospitals out there. Things that make a job terrible:

1. being forced to work way faster than your comfort level
2. not having specialty backup
3. poor ED resources
4. terrible RN group
5. low pay
6. bad boss

So in the rare case that a med student asks for my opinion on interviewing I tell them to ask for a list of where the grads have gone in the last 2 years.

 

[Cerberus]

There are a lot of terrible jobs at community hospitals out there. Things that make a job terrible:

1. being forced to work way faster than your comfort level
2. not having specialty backup
3. poor ED resources
4. terrible RN group
5. low pay
6. bad boss

So in the rare case that a med student asks for my opinion on interviewing I tell them to ask for a list of where the grads have gone in the last 2 years.

Even if they ask for a list, how will they know if it is a terrible job? I barely have a handle on which places are terrible to work at in my own local geographic area, let alone in other states/cities and I'm nearing graduation.

 

[Glitterbox]

Even if they ask for a list, how will they know if it is a terrible job? I barely have a handle on which places are terrible to work at in my own local geographic area, let alone in other states/cities and I'm nearing graduation.

That's how I feel. When I ask about job placement post-residency, most tell me the number of people that went into fellowship or academics, and then the average salaries of those that went into the community. I haven't really heard work environment mentioned.

 

[deleted109597]

Put me down as another saying an interviewing medical student will have no idea what a list of recent graduate jobs means.
The only thing they may get from it is a sense that going to residency X allows them an opportunity to practice in location Y (or X). They won't care or know anything about PPH, RVU pay, nursing, the boss, etc.

I do agree that good career counseling is important.

 

[justaregularmed]

paper charting.

 

[Cerberus]

paper charting.

This more or less made a program DNR for me when applying for residency and looking for an attending job, it would have to be a dream job for me to even consider going back to paper charts.

 

[RustedFox]

paper charting.

yuuuuup. no waaaaaay

 

[bad virus]

yuuuuup. no waaaaaay

Lol, I actually liked program that had hand written notes along with an electronic ordering system. I hate typing or dictating notes and I'd rather just write them once while im doing my interview and physical on paper and not copy them from paper to the computer.

 

[StevieStud]

so what do you do when your 'puter is down?

what do you do when you "treat" a patient on the side?


learning to use paper charts is a skill everybody needs to know. Deal breaker? Nah, a deal breaker is being treated like a burger flipper at McD and being required to "clock out" during slow parts of your shift.

 

[Iride28]

so what do you do when your 'puter is down?

what do you do when you "treat" a patient on the side?


learning to use paper charts is a skill everybody needs to know. Deal breaker? Nah, a deal breaker is being treated like a burger flipper at McD and being required to "clock out" during slow parts of your shift.

Yeah, I agree. I don't understand the fear of paper charts. You can leave a patients room and be done with everything except the medical decision making part. I prefer paper honestly.

 

[justaregularmed]

Yeah, I agree. I don't understand the fear of paper charts. You can leave a patients room and be done with everything except the medical decision making part. I prefer paper honestly.

I get really tired of trying to translate ****ty illegible charting on paper. It really makes me want to scream sometimes. Institutions that are unwilling or unable to deploy EMR's obviously have some systemic issues, where does it stop?

 

[Rendar5]

I get really tired of trying to translate ****ty illegible charting on paper. It really makes me want to scream sometimes. Institutions that are unwilling or unable to deploy EMR's obviously have some systemic issues, where does it stop?

Unable to deploy? sure. I can buy that there are systemic issues if tha'ts the case. But unwilling to? EMR charting as it currently stands is clumsier and a much higher time burden than paper charting. I've done both, and have had to consistently stay longer after my shift or work at a slower pace when I do electronic charting.

 

[jbar]

Yeah, I agree. I don't understand the fear of paper charts. You can leave a patients room and be done with everything except the medical decision making part. I prefer paper honestly.

The real time saver is when the patient returns for another visit and things like meds and PMD etc automatically populate into the new record, as well as the ability to actually read what the last person wrote who saw the patient for the same complaint 2 weeks ago.

That plus that ability to run "macros," presets that you can run to populate the EMR with a normal neuro exam, or normal gyn exam and just change one or two things really sell me on EMR.

I think theres going to be a huge shift in the next few years as those who came of age with computers start to dominate the ER workforce. Because most of us can type much much faster than we can write.

Finally from a systems standpoint, it's much easier for the billing people to see what you did from an EMR than trying to decipher a hand written note. So my electronic order for a sling or my electronic procedure note for an LP goes right to the biller. And quicker turn around for the billing means money for the hospital. I think a lot of places aren't going to let you keep hand writing charts once they figure out it is costing them money.

 

[Rendar5]

The real time saver is when the patient returns for another visit and things like meds and PMD etc automatically populate into the new record, as well as the ability to actually read what the last person wrote who saw the patient for the same complaint 2 weeks ago.

That plus that ability to run "macros," presets that you can run to populate the EMR with a normal neuro exam, or normal gyn exam and just change one or two things really sell me on EMR.

I think theres going to be a huge shift in the next few years as those who came of age with computers start to dominate the ER workforce. Because most of us can type much much faster than we can write.

Finally from a systems standpoint, it's much easier for the billing people to see what you did from an EMR than trying to decipher a hand written note. So my electronic order for a sling or my electronic procedure note for an LP goes right to the biller. And quicker turn around for the billing means money for the hospital. I think a lot of places aren't going to let you keep hand writing charts once they figure out it is costing them money.

we did T sheets at my job when I first started, much faster paper charting with that format than what I did with residency paper charting. electronic orders, but paper charting. when we transitioned to full EMR, still takes me 5+ minutes to chart someone where it used to take 2 minutes. And I do type much faster than I write, but I circle and slash faster than I click, and I turn that one sheet of paper around faster than I can click through 6 separate sections of my EMR. In addition, total billing at my current place has gone down since we swapped. (The coders were extremely extremely good, and now with EMR, not all providers are trained to perform maximal billing).

My point is not that paper charting is superior to electronic charting (in fact, I'd much prefer it to the paper charting used in my residency program). It's that some forms of paper charting are very efficient and some aren't, and the same applies to electronic charting (in my n=6 experience). So just cause a place has transitioned to an EMR, doesn't mean they're more efficient or bill higher. Please be cautious if you use it as a criteria, because it can mislead you if you look blindly.

 

[Apollyon]

At my new job, we use MedHost for the EMR. I cranked out a legitimate, serious, tight-as-a-drum, complete, legible chart in 2 minutes. The only "macro" was "agree with nurse's note", included free-type MDM (with my narrative), and was a solid level 5 chart.

I'm just sayin' - I used T-sheets at my last job, and I thought they sucked. No room for good MDM to be documented, led easily to laziness, then sloppiness, and were useless for return visits save the diagnosis (except when that was illegible, vague, or even not clearly circled - when two dx are each bisected by one part of the circle, that doesn't really help).

I am a fair 50-60 WPM typist, somewhat a child of the computer generation, and not resistant to technology (no matter what I say when I describe myself as a "neo-Luddite").

 

[Rendar5]

At my new job, we use MedHost for the EMR. I cranked out a legitimate, serious, tight-as-a-drum, complete, legible chart in 2 minutes. The only "macro" was "agree with nurse's note", included free-type MDM (with my narrative), and was a solid level 5 chart.

I'm just sayin' - I used T-sheets at my last job, and I thought they sucked. No room for good MDM to be documented, led easily to laziness, then sloppiness, and were useless for return visits save the diagnosis (except when that was illegible, vague, or even not clearly circled - when two dx are each bisected by one part of the circle, that doesn't really help).

I am a fair 50-60 WPM typist, somewhat a child of the computer generation, and not resistant to technology (no matter what I say when I describe myself as a "neo-Luddite").

Please convince them to move that over to my current job! I could use a typist friendly EMR.

 

[engineeredout]

Other things that irk me about programs, but aren't necessarily deal breakers would be:
1) programs that don't tell applicants that alcohol won't be included at pre-interview dinner

^This. Especially when I've had several pre-interview dinners at BREW HOUSES. You're taking us to a place whose specialty is their homemade beers and all you're covering is diet soda?

 

[deleted109597]

^This. Especially when I've had several pre-interview dinners at BREW HOUSES. You're taking us to a place whose specialty is their homemade beers and all you're covering is diet soda?

Some places have these pesky things called laws where they aren't allowed to purchase alcohol. Other places just have it in their hospital bylaws.
Passing the hat might work at a few, but often the residents are reticent to do so.
I agree that it is annoying, but a $5 beer shouldn't make or break anyone.
Conversely, if we know you're the student buying the most expensive thing on the menu just because you can, we will rank you accordingly.

 

[migm]

Conversely, if we know you're the student buying the most expensive thing on the menu just because you can, we will rank you accordingly.

how do you know if someone is choosing an item with malignant intent? what if they.. say.. wanted a steak?

 

[teacherman]

how do you know if someone is choosing an item with malignant intent? what if they.. say.. wanted a steak?

Haha! Yeah, I usually just ask the waitstaff or a resident what they recommend. Hope my culinary indecision hasn't slid me down too many lists!

 

[Cerberus]

At my program you can order more or less whatever you want. Our interview social is for the applicant, not us. You'd have to either make an extremely good impression or a very bad impression for it to at all affect your ranking.

 

[deleted109597]

how do you know if someone is choosing an item with malignant intent? what if they.. say.. wanted a steak?

It's not the steak. It's the surf and turf. Or the bison. Or something else that costs $60 when the rest of the plates are less than $30.

Honestly, if you order it and are nonchalant, nobody will ding you for it. But the common incident is that someone orders it knowing it's the most expensive, and then talks/brags about it.
#thingspeopledothataredoucheybuttheydon'tknowit

 

[FSU2013]

It's not the steak. It's the surf and turf. Or the bison. Or something else that costs $60 when the rest of the plates are less than $30.

Honestly, if you order it and are nonchalant, nobody will ding you for it. But the common incident is that someone orders it knowing it's the most expensive, and then talks/brags about it.
#thingspeopledothataredoucheybuttheydon'tknowit

Hope I wasn't "that guy" - I got the strip at a nice restaurant recently. I normally go with something middle of the road, but it was my third interview in a week and I wanted a dang steak. Like you said, I didn't get the strip and lobster with crab cakes as my side.

 

[StevieStud]

I had the swordfish at an interview.

Great seafood joint, sitting around discussing the menu..... I said something about never having tried swordfish.... and one of the residents encourage me to give it a try.... he had it last year and it was really good.


There be the hint. Do what others do. Talk about the menu and measure the response. If all of the residents are ordering the $9.95 chicken alfredo, you might want to adjust your selection as well

 

[Akail]

Are we seriously discussing how to strategically order food? C'mon SDN! Get what you have a hankering for and don't try to game the system, IMHO.

 

[DreamingTheLive]

Some places have these pesky things called laws where they aren't allowed to purchase alcohol. Other places just have it in their hospital bylaws.
Passing the hat might work at a few, but often the residents are reticent to do so.
I agree that it is annoying, but a $5 beer shouldn't make or break anyone.
Conversely, if we know you're the student buying the most expensive thing on the menu just because you can, we will rank you accordingly.

Beyond silly. So your program analyzes the motives of applicants food choices? Does an applicant have to provide evidence/history of truly enjoying a filet before being allowed to order such? What a joke. Why not just take your applicants to McDonalds and limit their choices to 3 items from the dollar menu. I don't believe in residency program deal-breakers per se, but hearing this about a program whould definitely give me pause.

 

[teacherman]

Beyond silly. So your program analyzes the motives of applicants food choices? Does an applicant have to provide evidence/history of truly enjoying a filet before being allowed to order such? What a joke. Why not just take your applicants to McDonalds and limit their choices to 3 items from the dollar menu. I don't believe in residency program deal-breakers per se, but hearing this about a program whould definitely give me pause.

Next thing you know there will be a bowl of Lays potato chips in the break room with a sign informing you that you move down then rank list with each chip.

 

[ERdocSGU]

This is all incredible to me that there are programs out there hosting dinners at steak houses. I haven't come across this yet. I have been to quite a few thus far where it is pay for your own meal and drinks. I actually prefer this.... The residents who show up actually want to be there. They aren't getting free food out of spending an evening with you. With this set up I was actually surprised how many residents showed up. Granted, we weren't in NYC where things are super expensive, but it said a lot about the residents being welcoming, friendly, and enjoying each others company.

 

[FMtoEM]

You are supposed to be wined and dined. Never ever had to buy my own food during pre-interview dinners. You are already spending a good bit of money to interview with them.

 

[EM2013woot]

I have been to quite a few thus far where it is pay for your own meal and drinks.

Lame. This would immediately push the program down my list. Not because I care about paying $20 bucks for a meal out, but because I'd take it as a sign of how the program views/supports its residents and prospective residents.

 

[winkleweizen]

Lame. This would immediately push the program down my list. Not because I care about paying $20 bucks for a meal out, but because I'd take it as a sign of how the program views/supports its residents and prospective residents.

Kind of agree here. Im ok with not paying for drinks, but they couldnt even give you a free burger?

 

[Lanolin]

This is all incredible to me that there are programs out there hosting dinners at steak houses. I haven't come across this yet. I have been to quite a few thus far where it is pay for your own meal and drinks. I actually prefer this.... The residents who show up actually want to be there. They aren't getting free food out of spending an evening with you. With this set up I was actually surprised how many residents showed up. Granted, we weren't in NYC where things are super expensive, but it said a lot about the residents being welcoming, friendly, and enjoying each others company.

I interviewed at a program recently that dropped $2500 on sushi for the applicants and residents. Tasty indeed!

 

[GoGetEM]

I interviewed at a program recently that dropped $2500 on sushi for the applicants and residents. Tasty indeed!

Wow, where was that?

 

[bad virus]

Wow, where was that?

I'm guessing one of the items was a Corey roll (aka Vandy)

Btw, Cinci puts you up in the Hilton for 2 nights and takes you out to a super fancy place for dinner. Do any programs top that?

 

[Old_Mil]

Quick questions here, how does lunch break work for you guys? Is it a designated time slot or you just figure out the best time with each shift? do you sign out your patient to another resident? critical patients? who is responsible for critical labs resulted during your break?

You eat in much the same way an antelope in the Serengeti does: quickly, and looking up frequently to check for predators.

 

[Cerberus]

You eat in much the same way an antelope in the Serengeti does: quickly, and looking up frequently to check for predators.

👍👍

 

[TeamZissou]

You eat in much the same way an antelope in the Serengeti does: quickly, and looking up frequently to check for predators.

Hahaha fantastic

 

[21isFun]

I interviewed at a program recently that dropped $2500 on sushi for the applicants and residents. Tasty indeed!

Wow, and I was impressed that Mayo Clinic encouraged everyone to order Filets, got fondue and seared ahi for appetizers, and then told us that we should order dessert "to go" even if we were too stuffed to eat it then, and we could just eat it later. They seemed proud of their rep for "feeding candidates well" and claimed they didn't want to disappoint.

But seriously, wow, $2500 on sushi. If I was a Vandy resident, I'd be making time to show up to interview dinners just for the cuisine!