Resident ITE scores have plummeted 25% in the last 5 years

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I just need this specialty to hold out for 10 years, please. Please just let me get that bag for a little bit longer. Hoping the confluence of 4 year programs/IMG fest/Medicaid cuts/midlevel takeover all take just a little bit longer to be realized.
 
No shock.. more HCA residencies.. more low tier students (define them as you wish) and this is what you get. Throw in the reality that this new generation of medical students doesnt want to put in work. This is the proof in my opinion. They expect to be spoon fed everything, dont want to work hard. The results are not good for patients.
 
EctopicFetus said:
No shock.. more HCA residencies.. more low tier students (define them as you wish) and this is what you get. Throw in the reality that this new generation of medical students doesnt want to put in work. This is the proof in my opinion. They expect to be spoon fed everything, dont want to work hard. The results are not good for patients.
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This. I just saw a patient the other day who was seen ~1 week earlier by a "good" PA. They apparently attributed to the patient's mild confusion to hyponatremia, treated it with 1 L NS and discharged them. Aside from gross mismanagement of hyponatremia, the patient didn't have hyponatremia, they were hyperglycemia with a normal corrected sodium. Moments like this make me wonder what future exists in medicine. No one cares about quality of care and there are no self correcting mechanisms in the system. Why should I bother to invest in my clinical skills if that is acceptable care?
 
There's this idea that you can create a de-risked learning environment for residents and if you can set things up just right, you can create procedurally and clinically competent attendings without all the messiness of failure, hurt patients, hurt feelings, and stress that was the hallmark of EM training since its inception. Sim labs can simulate procedures that are dangerous and uncomfortable for both patient and doctor, constant attending supervision and relegation of residents to "interested observer status" during key moments of decision-making makes sure nobody gets too hurt or stressed about their ability to make decisions under fire, etc...

And it's gone too far.
 
MechEDoc said:
This. I just saw a patient the other day who was seen ~1 week earlier by a "good" PA. They apparently attributed to the patient's mild confusion to hyponatremia, treated it with 1 L NS and discharged them. Aside from gross mismanagement of hyponatremia, the patient didn't have hyponatremia, they were hyperglycemia with a normal corrected sodium. Moments like this make me wonder what future exists in medicine. No one cares about quality of care and there are no self correcting mechanisms in the system. Why should I bother to invest in my clinical skills if that is acceptable care?
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Yeah. The hospitals and groups (mostly CMGs) coddle the noctors cause they are their profit center. Complain to the medical director and get some BS response.
 
Arcan57 said:
There's this idea that you can create a de-risked learning environment for residents and if you can set things up just right, you can create procedurally and clinically competent attendings without all the messiness of failure, hurt patients, hurt feelings, and stress that was the hallmark of EM training since its inception. Sim labs can simulate procedures that are dangerous and uncomfortable for both patient and doctor, constant attending supervision and relegation of residents to "interested observer status" during key moments of decision-making makes sure nobody gets too hurt or stressed about their ability to make decisions under fire, etc...

And it's gone too far.
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Do residents really not get that true experience of not being entirely sure if they're about to throw up or poop themselves because of stress and still be able to perform? Better to learn it in residency.
 
TooMuchResearch said:
Meanwhile residents on reddit complain the exam isn't fair. It's not my fault! The test is bad! My group doesn't hire these people.
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Isnt this always the answer when someone fails. It is never their fault is is always bias, too random etc. Listen the test when i took it was dumb, had some weird questions etc. Meanwhile I passed.. as did 90% of other EM trained people. The test isnt harder.. the docs are dumber.
 
TooMuchResearch said:
Do residents really not get that true experience of not being entirely sure if they're about to throw up or poop themselves because of stress and still be able to perform? Better to learn it in residency.
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My residents get this. I tell them.. im in the room but im not saying a word.
 
TooMuchResearch said:
Meanwhile residents on reddit complain the exam isn't fair. It's not my fault! The test is bad! My group doesn't hire these people.
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Lol was just about to make this same comment, but about the newly fledged attendings claiming on Reddit that the written and oral boards are now harder because more of them are failing despite the abrupt increase in failure rates coinciding exactly with the drop in competitiveness of EM.
 
The field has failed.

It was a good go. Noble idea to make EM a specialty to make sure patients had a doctor trained in acute undifferentiated workups and resuscitation.

But society has decided we aren't of any value. The good medical students are taking heed of this and avoiding the field like the plague.

We're the only field that has experienced a negative change to real inflation adjusted pay in the last few years.

It's over. Save up and get out.
 
Some of this lines up with Covid restrictions... both during residency as well as limited rotations during medical school.

Every specialty has gone through this cycle. The sky is not falling.
 
southerndoc said:
Some of this lines up with Covid restrictions... both during residency as well as limited rotations during medical school.

Every specialty has gone through this cycle. The sky is not falling.
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Its falling.. will it collapse who knows? U Sucks drama just starting up.. will be curious what it all means.
 
EctopicFetus said:
My residents get this. I tell them.. im in the room but im not saying a word.
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That's great. Some of my interns (to be fair, they're not EM) act like they've never had to synthesize a differential diagnosis for an undifferentiated patient. You've been a doctor for 11 months, surely you can name more than 2 causes of belly pain without having to be carried there.
 
EctopicFetus said:
Isnt this always the answer when someone fails. It is never their fault is is always bias, too random etc. Listen the test when i took it was dumb, had some weird questions etc. Meanwhile I passed.. as did 90% of other EM trained people. The test isnt harder.. the docs are dumber.
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Yeah my test definitely had some "I have no idea what I'm supposed to pick but go with my gut" questions and still did quite well.
 
I trained in a shock trauma top 3 volume ER in the late 1990s. Attendings were rarely around, we would be lucky to have 2 attendings staffing the whole ER. Off service never saw an attending past about 11am or atleast I never saw them. About the best learning I could have had. I didn't fear anything leaving training. I saw and did things I have never done since leaving residency as an attending. I have done procedures my fellow attendings never do.

It was a great experience and looking back I was over trained when I went into the community hospital life. I dare say 99.9% of new grads never did/saw what I did.
 
TooMuchResearch said:
Okay good.
My attendings would only step in if absolutely needed.
You're one of the good guys, Dr. Fetus.
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About a month ago.. resident and I were doing a mandible dislocation. He couldnt get it in. HE asked me if i wanted to try. I said no. Time for a new strategy. We ended up sedating the guy and he popped it in. I think I have been doing this enough that my patience is pretty high. I also have done a ton of procedures in my career and I cant think of a single procedure where I am like man I wish I could do that myself. I work some shifts without residents so they pop up on occasion.
 
EctopicFetus said:
About a month ago.. resident and I were doing a mandible dislocation. He couldnt get it in. HE asked me if i wanted to try. I said no. Time for a new strategy. We ended up sedating the guy and he popped it in. I think I have been doing this enough that my patience is pretty high. I also have done a ton of procedures in my career and I cant think of a single procedure where I am like man I wish I could do that myself. I work some shifts without residents so they pop up on occasion.
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I have some anxiety about allowing residents (particularly juniors) perform certain procedures.

Mainly:

-FO NT intubations in angioedema
-Pericardiocentesis in patients whom are alive
-To a lesser extent, crics

In my mind these are mainly situations where the first attempt is your best attempt and should be performed by the most experienced operator. How do I reconcile this without compromising their education?
 
Jabbed said:
Pericardiocentesis in patients whom are alive
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I don't know why but that made me laugh

probably flashing back to all the dead nursing home patients my attending told me to do a pericardiocentesis on lol
 
AlmostAnMD said:
I don't know why but that made me laugh

probably flashing back to all the dead nursing home patients my attending told me to do a pericardiocentesis on lol
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Probably because I was specifically referring to not that scenario 😉
 
It's a good thing to practice! Did it twice as an attending on a peri-arrest patient waiting for IC to come in and place a drain

they probably laughed at my concoction of LP kit/art line stuff I assembled to make a drain

whatever works
 
AlmostAnMD said:
It's a good thing to practice! Did it twice as an attending on a peri-arrest patient waiting for IC to come in and place a drain

they probably laughed at my concoction of LP kit/art line stuff I assembled to make a drain

whatever works
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You should just have them stock the drain kits in the ED. They are significantly nicer than the whatever spinal needle/CVL/art line mash-up we are taught to come up with.

Separate point, but it amazes me what we’re inculcated to accept as appropriate equipment for performing life-saving procedures under high stakes. When I started at my current gig the “pericardiocentesis tray” was a spinal needle with a 10 cc syringe. The gauge was too small and the needle too long so you couldn’t even aspirate anything through it.

Imagine calling in IC, handing them that tray and telling them “you have to sedate and prep the patient on your own and oh by the way the overhead light doesn’t work. Also, the family wants an update.”

We’re not in Somalia. All the right equipment to do this is one floor up in a closet. Just stock that **** in the ED!

/rant
 
Jabbed said:
You should just have them stock the drain kits in the ED. They are significantly nicer than the whatever spinal needle/CVL/art line mash-up we are taught to come up with.

Separate point, but it amazes me what we’re inculcated to accept as appropriate equipment for performing life-saving procedures under high stakes. When I started at my current gig the “pericardiocentesis tray” was a spinal needle with a 10 cc syringe. The gauge was too small and the needle too long so you couldn’t even aspirate anything through it.

Imagine calling in IC, handing them that tray and telling them “you have to sedate and prep the patient on your own and oh by the way the overhead light doesn’t work. Also, the family wants an update.”

We’re not in Somalia. All the right equipment to do this is one floor up in a closet. Just stock that **** in the ED!

/rant
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Goes back to what I said about how we are not assigned value. If we were, the ED would be stocked. Instead I spent 30 minutes last week trying to find alligator forceps.

Do you think the Orthopedist goes to look for his own arthroplasty equipment?

The tragedy is I had better scores than most orthopedists.
 
WhatJobDoIPick said:
Goes back to what I said about how we are not assigned value. If we were, the ED would be stocked. Instead I spent 30 minutes last week trying to find alligator forceps.

Do you think the Orthopedist goes to look for his own arthroplasty equipment?

The tragedy is I had better scores than most orthopedists.
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This is what really grinds my gears about EM when I chose it.

I could have picked derm, plastics, radiology, you name it with the scores and name recognition of my medical school

But instead I thought I wanted to "help people" and wanted to do something "important for all humans" and something that made women interested in me when I told them what I did for a job

I was a mor0n back then (still am, but at least I'm not praciting EM any more, which makes me slightly less of a mor0n/regard)
 
WhatJobDoIPick said:
Goes back to what I said about how we are not assigned value. If we were, the ED would be stocked. Instead I spent 30 minutes last week trying to find alligator forceps.

Do you think the Orthopedist goes to look for his own arthroplasty equipment?

The tragedy is I had better scores than most orthopedists.
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Very true. I like decent quality suture sets. EM sutures quite a bit but most ERs are stuck with single use poorly made sets from Pakistan that barely can grasp a needle. Can you imagine surgeon tolerating this? Since I'm generating thousands per hour, why can't I get a decent set of hand tools?
 
MechEDoc said:
What are you practicing now?
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I "practice" selling options on my sizeable stock positions that I accumulated while "living like a resident" during my entire attending stint

It gives me enough income to be fully retired. Wife works and I get insurance through her job.

I tried finding some physician-type work in my area, but the EM training is so useless outside of the ED that most gigs/hustles/options see you the same way as a PA or NP. There's no difference between me and a midlevel in the obesity, urgent care, and aesthetics type hustles. I've written a few long-form posts about it. I even tried doing a subscription-based DPC-style thing, and it became abundantly clear to me that this wasn't a viable solution either after investing approx $10k into it. The bottom line is that in a desirable VHCOL area, there's not much you can do with an EM board cert (outside of EM) that pays anything that I think is worth the time and effort ($300-400/hr+).

It's stunning to think about. I can make more money selling options than doing some non-EM patient care work for 40 hours per week.
 
EctopicFetus said:
No shock.. more HCA residencies.. more low tier students (define them as you wish) and this is what you get. Throw in the reality that this new generation of medical students doesnt want to put in work. This is the proof in my opinion. They expect to be spoon fed everything, dont want to work hard. The results are not good for patients.
Click to expand...

"The test is racist! It doesn't reflect the fact that we need to consider socioeconomic barriers to care as the most important...."

STFU.
 
RustedFox said:
"The test is racist! It doesn't reflect the fact that we need to consider socioeconomic barriers to care as the most important...."
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So the test outcomes support the conclusions of "The Bell Curve: Intelligence and Class Structure in American Life"? I thought that book was supposed to be racist..!

This is all getting so confusing. 😉
 
HemorrhagicShock said:
I "practice" selling options on my sizeable stock positions that I accumulated while "living like a resident" during my entire attending stint

It gives me enough income to be fully retired. Wife works and I get insurance through her job.

I tried finding some physician-type work in my area, but the EM training is so useless outside of the ED that most gigs/hustles/options see you the same way as a PA or NP. There's no difference between me and a midlevel in the obesity, urgent care, and aesthetics type hustles. I've written a few long-form posts about it. I even tried doing a subscription-based DPC-style thing, and it became abundantly clear to me that this wasn't a viable solution either after investing approx $10k into it. The bottom line is that in a desirable VHCOL area, there's not much you can do with an EM board cert (outside of EM) that pays anything that I think is worth the time and effort ($300-400/hr+).

It's stunning to think about. I can make more money selling options than doing some non-EM patient care work for 40 hours per week.
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What went wrong with DPC? Did you find people to cheap to be willing to pay for their own medical care?

On a tangent, I'm pretty clueless about put options, but I have a problem that I might be able to solve with one.

Let’s say I own a bunch of VTSAX (Vanguard total Stock market Index fund) in a taxable account; I would like to sell these funds now and place them in a money market account so that I can lock in my current gains and use the money for anticipated expenses (e.g. real estate purchases) within the next 12 months. However, for reasons that I cannot elaborate on, it is unwise for me to sell this until next year. To hedge against a possible downturn in the stock market I would like to purchase a put option as a sort of insurance policy. I understand that I can’t purchase a put option against a mutual fund but could do so against VTI which is a virtually identical composition.

Is this the best approach? Any gotchas to be aware of?
 
MechEDoc said:
What went wrong with DPC? Did you find people to cheap to be willing to pay for their own medical care?

On a tangent, I'm pretty clueless about put options, but I have a problem that I might be able to solve with one.

Let’s say I own a bunch of VTSAX (Vanguard total Stock market Index fund) in a taxable account; I would like to sell these funds now and place them in a money market account so that I can lock in my current gains and use the money for anticipated expenses (e.g. real estate purchases) within the next 12 months. However, for reasons that I cannot elaborate on, it is unwise for me to sell this until next year. To hedge against a possible downturn in the stock market I would like to purchase a put option as a sort of insurance policy. I understand that I can’t purchase a put option against a mutual fund but could do so against VTI which is a virtually identical composition.

Is this the best approach? Any gotchas to be aware of?
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Yea building a practice is mostly a marketing game (expensive, difficult, and requires niche expertise), and I also realized how over my head I was since a majority of the initial interest was from those with multiple chronic issues. Think the 65-year-old with HFpEF, mild COPD, HTN, and chronic pain from who knows what. I quickly realized that this was going to be way more complicated than sitting at my computer, clicking buttons intelligently, and making solid money.

I could write a whole thing about it, but it's not as easy as it seems. I tried to transition to more of a DPC urgent care model, but people don't have a lot of need for that with all the fancy high-functioning urgent cares in my area. Remember, laypeople don't know that a PA or NP at a fancy-looking urgent care is poor quality. They just want their script, or note, or whatever, and thus it's hard to compete with an established operation with tons of google reviews, word of mouth reviews, and other inertia.

As for your options question, here's the best piece of advice I can give you, because answering it requires a pretty solid options 101 knowledge base.

Take your exact string of text that you posted above, From "Let's say i own...." to "Any gotchas to be aware of" and paste it directly into ChatGPT, Perplexity, Gemini, Grok, Claude, or whatever AI/LLM you have access to and add "explain this to me as if I have no experience trading options and want to learn."

If you've never used AI/LLMs before, consider this your opportunity to learn two skills at once.

I'm not trying to blow off your question, it's just that it has such an in-depth, complex, and multi-faceted answer that you're better off going at it in a step-wise way with an LLM who can drill down the pain points when it comes to your understanding.

Also post any questions you might have on the output in the options chat since I'm already derailing the crap out of this thread!
 
AlmostAnMD said:
I don't know why but that made me laugh

probably flashing back to all the dead nursing home patients my attending told me to do a pericardiocentesis on lol
Click to expand...
Me: I don't think that pericardial effusion was there when we started CPR.
Attending: It's there now.
Me: Already have the big ****ing needle and big ****ing syringe.
 
MechEDoc said:
So the test outcomes support the conclusions of "The Bell Curve: Intelligence and Class Structure in American Life"? I thought that book was supposed to be racist..!

This is all getting so confusing. 😉
Click to expand...

Haha one of my favorite books. I read it when I was around 27 yo. Completely changed my outlook on life and in a way made me more understanding when dealing with people going about my daily life.
 
Emapp20177 said:
If you think that's bad, just wait until all programs are 4 years. Apparently, according to the leaders of the field, EM needs is another reason for talented students to avoid it.
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I cant wait. It is gonna be great. /sarcasm In many ways one of the things I like about EM is the chaos. This will breed insane chaos.
 
It’s gonna be such an epic collapse in competitiveness of EM I sort of look forward to the chaos.
 
EctopicFetus said:
It’s gonna be such an epic collapse in competitiveness of EM I sort of look forward to the chaos.
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Im all for the change to 4 year and the new requirements if it causes programs to close. If you’re a practicing attending how could you not root for this?
 
drerp88 said:
Im all for the change to 4 year and the new requirements if it causes programs to close. If you’re a practicing attending how could you not root for this?
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I think maybe if I was new and a bit more selfish I would be all for pulling up the ladder behind me.

I’m not for it. It’s dumb and unnecessary and speaks to the ignorance and stupidity of AcEP leaders.

It’s overall bad for patients but it is good for practicing eps.
 
EctopicFetus said:
It’s gonna be such an epic collapse in competitiveness of EM I sort of look forward to the chaos.
Click to expand...

I'm hearing from medical students I mentor (I still do stuff with the local medical school and volunteer in a capacity where I run into a lot of medical students) that EM is back to being super popular.

I cannot help but feel disgusted and disappointed that the propaganda machine for EM is alive and well.

I wouldn't have listened to myself though when I was a medical student if I went back in time and said "DON'T DO IT!"

It must be that Pitt show... sad.
 
Yeah.. we had probably our strongest match ever. Super strong students. I feel for the youth..
 
Arcan57 said:
There's this idea that you can create a de-risked learning environment for residents and if you can set things up just right, you can create procedurally and clinically competent attendings without all the messiness of failure, hurt patients, hurt feelings, and stress that was the hallmark of EM training since its inception. Sim labs can simulate procedures that are dangerous and uncomfortable for both patient and doctor, constant attending supervision and relegation of residents to "interested observer status" during key moments of decision-making makes sure nobody gets too hurt or stressed about their ability to make decisions under fire, etc...

And it's gone too far.
Click to expand...

I was a IM resident, but even then some of this was starting to happen. Thankfully I was in a program where they still let us do unsupervised overnight call etc…because while it’s fine to practice in a sim lab etc, at some point the rubber has to hit the road and you have to do the procedure on your own in the heat of the moment. Or else you don’t know what you’re doing.

Same thing with “supervision”, usually done in the name of “patient safety”. But would you rather have the residents learn things and make mistakes in residency - a semi controlled environment where there is some supervision - or when they are new attendings, where there is no supervision whatsoever? Isn’t it a “patient safety” issue to turn out new doctors who don’t feel comfortable/confident doing things because they’ve never had to do it on their own?
 
I skipped a bunch of responses (ADHD hitting *hard* tonight). Did we have any clear theories on why it suddenly went from a 1-2% score drop yearly to a 13% drop in average score suddenly? Also that it dropped across the board, so its not like the 2025 entering class is stupid - because its 2nd and 3rd years ****ing up too.

was the test suddenly unusually hard? Did AI just sap everyone of their ability to study? Did the downstream effects of covid during the first year of medical school finally present themselves in the current intern class?
 
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