Residency with no other Residency Programs..Ranking?

[Pegasus]

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I am trying to sort out my match list, and there is a program that I am interested in, however EM is basically the only residency in the hospital besides Family.

I worry that this may have a negative impact on my education as a resident, and I was wondering what everyone else thought? Is a program stronger if they have other residents who are also learning, or is the one on one time with an attending on off service rotations a better education(esp in the ICU)?

Thanks

 

[Chris_Topher]

Well now, this is a good question. One that should be asked more often regarding EM programs.

I went through med school and the application process thinking that I wanted to go to a program with all of the sub-specialties, thinking that I would learn by having all of these excellent consultants around to share ideas with. I matched at such a program. We have ortho-spine, ortho-hand, ortho-trauma, GI surgery, GI medicine, GI radiation, infectious disease, oral surgery, Double-Secret Neurosurgery, and many others. What I have found is that I spend less time thinking through the appropriate treatment of problems and more time calling my consultants. Do I learn from my consultants? Some, but most just come leave a note on the chart or admit my patient without telling me. I have learned while doing the specific off-service rotations, and some by osmosis, but I do not necessarily feel as thought I am being trained to practice in a small community setting without all of these services. Can I splint this to be seen in a week or do I need to transfer now?

On the flip side, if I were at a smaller community hospital without all of these services, would EMS keep driving right on past my hospital to the big county hospital? Would I continue to see all of this crazy pathology? Probably not.

So, I tried not to answer your question, but instead confuse you. You might ask youself, where do I plan to practice? In what setting do I want to be prepared to see patients? Then throw away your answer because it might be wrong in 3 years.

[DISCLAIMER: this written by post-shift intern. Take with a grain of salt]

 

[basementbeastie]

excellent synopsis of issues that i have also been thinking about lately. during the various components of the interview process, i have tried to assess that by asking the EM residents about when and how consultants are called in, how much learning they get from them, if procedures are lost to them, and if certain patient types ever get siphoned off to a specialty service with little ED interventions. this is, of course, subjective and hard to evaluate. good luck.

 

[jazz]

Chris_Topher brings up several excellent points. there are two different em philosphies -- learn from em trained attendings (ie --limited off service rotations and mainly er rotations) vs. lots of off service rotations and learning from specialists in the field.

a hospital with only EM and FP may "lose" the more critically ill patients to other hospitals, especially if there are larger academic/community hospitals nearby.

a better bet may be to train at a hospital/program where EM has more "pull" in other words, a place where the em is a department and has department status. you're less likely to get to place chest tubes and whatnot in the er on your own if you are a division of surgery. train at a place where em is established. realistically, em is stronger in places where im and surgery are weaker. in other words, the big name medicine and surgery places, in general, have weaker EM programs. this is mainly because em is a newer specialty and thus weaker in the hospital scheme of things

so when you look at the em programs you are applying to, consider what basementbeastie says -- who does the procedure, do you learn from your consultants, where do you do your icu months -- are you "just" a rotator or an integral team member, etc, etc....

 

[dread]

This is a good question. I think that there are pluses and minuses for doing your residency at a non-academic medical center. My impression is that EM residents who work at academic centers consult early and often, because the residents and fellows that they are consulting usually can't say no. I suspect that at non-academic medical centers, you will have a little more difficulty in getting, say a neurosurgery consult at 3 am in the morning then you would if there were a neursurgery resident on call in the hospital. So I imagine that your autonomy in your training would be increased. But then I imagine that the teaching may be worse at such hospitals too, since the attendings on other services aren't there to teach and don't have a lot of experience in it. They are also more likely to practice non-standard of care medicine and be less up to date on the newest guidelines. Also, if you did want to work in academics or go on to do a fellowship, I think that your chances are better at academic centers with other residency programs.

 

[jpgreer13]

My personal school of thought on this one is that you didn't go into emergency medicine to learn to think like a surgeon or an internist. You go into emergency medicine to learn to think like an emergency physician, and that means you need to spend time working in the ED seeing and treating ED patients. Yeah, I'm doing cardiology this month, and I think the time I spend standing around in rounds with my hands stuck in my pockets while internal medicine types discuss whether to give statins or whether we need to check a fasting lipid panel is time I'll just never get back. I learn more cardiology in the ED where the pathology is acute than I do just watching these people on monitors on the floors and units. By the time you see them, the ED physicians have already worked them up and initiated the treatment, and that leaves you nothing to do on off-service rotations but clean up the details. You can make the argument that by rotating off-service, you learn from "experts in the fields", but I contend that I'm not going into that field, and I'd rather rotate in the ED, learning from the experts in MY field.

That's one of the big selling points of ECU, I think. It's got a fairly limited residency selection (EM, FP, IM, psych, general surgery, cards fellows, PM & R, OB/GYN, and that's about it). However, it's also the only hospital in this town, so you can't bypass it, and it covers everything basically between Raleigh and the ocean in Eastern North Carolina. There's an insane amount of pathology, as this place might lead the free world in renal disease and HIV per capita, and there's a good mix of residents and private attendings to call. I had an interview at one place whose name I won't mention because someone there will pop up and tell me it's not true as soon as I say it, but I heard on the trail that this place is so ridiculously specialized it even has male and female Foley teams to go around and put catheters in patients of respective genders. I say, no way. I did med school at a place with plastic surgery residents, and just about every facial lac, we called those guys on. Here, I've sewn up good-sized face lacs without a second thought, and I think I'm better for the experience.

I must also add that there's no radiology residency here, which eliminates the frustrating experience I had at my med school of radiology residents reading films at night, and then the ED gets calls each morning with the attendings' overreads, and you have to call the parents of the little kid you sent home a few hours ago to tell them, "We're sorry, but after further review, your son really DOES have a broken arm."

 

[500gp]

If that program also has 4 internal medicine months attached to in working with privates, I'd say run!!!

 

[anonymousEM]

it also depends on what "special" things you're looking for in a program. I interviewed at one hospital with only EM and FP with a very impressive flight program. If you're looking to be the doc on Lifeflight for three years or more, maybe you'd rather not be in the ivory tower amongst the subspecialists. They made some amazing bucks moonlighting at that hospital too.

 

[The White Coat Investor]

You will almost surely learn emergency orthopedics better at a program without an ortho residency. Of course, your actual ortho rotation may not be as good.

Amen to the 4 IM months comment, but change it to 2!

I'm of the school of though that EM is best learned in the ED. Although I do learn some things off service, the learning curve is much steeper in the ED.