Rotations: Unit vs Floor?

[LadyGrey]

Some programs make a big deal about having more unit time and less floor time. (I.e., all peds is PICU, all medicine is ICU, all surgery is SICU). This sounds fabulous, not least of all because it decreases or nearly eliminates call. (One program promises 2 months of call in your entire residency).

So, what's the downside? There must be one, right?

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[domer621]

Some programs make a big deal about having more unit time and less floor time. (I.e., all peds is PICU, all medicine is ICU, all surgery is SICU). This sounds fabulous, not least of all because it decreases or nearly eliminates call.

Decreases call? Unit time is the worst for call, and are among the harder/hardest rotations. Usually q3 or q4. That is the downside!


The upside is that you see the sickest patients in the hospital.

 

[SoCuteMD]

I'm not exactly clear how being in the unit as opposed to on the floors decreases call. It definitely doesn't in the PICU and MICU at my hospital.

I'm in the ICU this month and I'd use one word to describe it: brutal. Maybe it's that I'm now a sub-i as opposed to an MS3, and maybe the fact that the person most junior next to me is already a PGY2 - but the expectations are high, there is TONS to be done in any given day, and the patients are SICK.

On the plus side, most ICU nurses are great (and then there's the occasional exception, which would be who one of my patients had today - boy did she make my day hell) and the resources available in the ICU are much easier to come by than on the floor.

 

[Universe_Explorer]

Unit months can be extremely rewarding in the context of how many procedures you can perform/learn (lines, tubes, etc), increasing you comfort level with treating sick patients (managing vents, pressors, etc), and the working environment - usually ICU nursing/physician staffs are tight-knit like the ED.

The flip side is that there is a lot more work - the patients are sick - lots of time is spent rounding, on codes, and doing procedures. At our program the call schedule is as intense or more than the floor months. I definitely worked harder on my ICU month than my floor month this year, but I got a LOT more out of the ICU month. I'm a big advocate of EM residencies that have a strong critical care component - you will find what you do in the Unit is much more applicable to the ED than what you do on the floor, and getting comfortable with the sickest patients never goes out of style.

 

[overthebars]

Unit months can be extremely rewarding in the context of how many procedures you can perform/learn (lines, tubes, etc), increasing you comfort level with treating sick patients (managing vents, pressors, etc), and the working environment - usually ICU nursing/physician staffs are tight-knit like the ED.

The flip side is that there is a lot more work - the patients are sick - lots of time is spent rounding, on codes, and doing procedures. At our program the call schedule is as intense or more than the floor months. I definitely worked harder on my ICU month than my floor month this year, but I got a LOT more out of the ICU month. I'm a big advocate of EM residencies that have a strong critical care component - you will find what you do in the Unit is much more applicable to the ED than what you do on the floor, and getting comfortable with the sickest patients never goes out of style.

Exactly.

 

[xaelia]

If you're a real ER doc, floor months will make you want to claw your eyes out. All you are on the floor is Discharge Planner, MD.

ICU is rough, but the return on investment is much higher.

 

[LadyGrey]

OK, I guess the call part is variable, depending on the program. At the last program I interviewed, they said their unit months were very tough (12-13 hour days, 6 days a week) but without any call. You were on either days or nights.

 

[southerndoc]

OK, I guess the call part is variable, depending on the program. At the last program I interviewed, they said their unit months were very tough (12-13 hour days, 6 days a week) but without any call. You were on either days or nights.

Ugh, try 4 days off on a 28-day rotation, 12 hr days, with call every 4th night.

 

[crewmaster1]

Ugh, try 4 days off on a 28-day rotation, 12 hr days, with call every 4th night.

This is every ICU rotation I've ever done! Floor stuff is often similar unless you have a night float system. Haven't seen many ICU night float systems.

However, getting an easier schedule shouldn't play all that much into your decision.....residency, after all, is the time to work super hard and learn as much as possible to make you a well trained EM doc. Believe it or not, it isn't the time of your life to pick the coolest city to live in or a program with the shortest, easiest work schedule. When I was interviewing it seemed like so many applicants were so worried about which city or area they were going to do residency...come on you're working a ton of hours and making crap for money, how about get the best training possible so you can control the rest of your life to get the best job in a city where you want to live and enjoy yourself while you're making 6 times as much money and working 1/3 the hours!

Get the ICU experience. Floors are a waste of time other than maybe 1 single month of floor medicine. Same reason why I didn't interview at any 2-4 programs...take a close look at what you do during your intern year, nowhere near as useful as the 1-4 programs schedules.

 

[LadyGrey]

However, getting an easier schedule shouldn't play all that much into your decision.....residency, after all, is the time to work super hard and learn as much as possible to make you a well trained EM doc.

Yeah, didn't mean too imply that I was looking for the easiest possible residency. That one of the selling points I'd heard was that it was easier to have more unit time was what was worrying me about it -- I was afraid that there might be a catch as far as something I'd be missing out on learning by not having floor months with more call. I think we all want to work hard and become well-trained, though I don't think it's crazy to be tempted by promises of avoiding suffering if it doesn't compromise learning in any way.

 

[GatorEM]

I'm in the unit right now and my schedule is Q4 27hr call and 10 - 12 hr days when not on call, which is pretty damn brutal. My IM rotation on the other hand was Q7 call until 8pm mixed in with crappy floor work somewhere in between functioning as a social worker/discharge planner/babysitter. Even though the unit schedule is tough, it's worth it given that I put in a central line and three art lines on my last shift and one of my fellow medical students put in a chest tube - I'm in a trauma ICU btw.

 

[deleted109597]

Ugh, try 4 days off on a 28-day rotation, 12 hr days, with call every 4th night.

Could be worse, you could have 4 days off on a 33 day month, with 9 hour days, but 7 of those hours you could be wanting to (or actively trying) to kill yourself because you have to keep tracking down case workers for discharge planning. Or writing discharge summaries of the ones you have dictated.

Also, your patients aren't sick at all on the floor usually. And if they really are, off to the ICU they go.

 

[deleted109597]

Floors are a waste of time other than maybe 1 single month of floor medicine.

You'd be hard pressed to convince me that this too wasn't a colossal waste of time, and I just got off of mine.

 

[crewmaster1]

You'd be hard pressed to convince me that this too wasn't a colossal waste of time, and I just got off of mine.

yeah, I agree. That was a big MAYBE. I supposed it could help teach you how little care people get on the floor, so you realize who needs to go to the step-down or unit. You could reaffirm why you didn't do medicine. I'm not sure. And surgery floor is even more worthless, ortho floor even more worthless. We take ortho-night float and just do consults all night, but I get sign-out from those poor daytime ortho floor interns. Anyways, look closely at what floor months you do in a program and what they think you'll gain from it. Especially if you are thinking 2-4 and want to do a transitional year!

 

[Jimmy1]

Unit months: 6-7 calls over 28 days, usually 12 hr days when not on call, 3 days off. lots of procedures, learn a ton about how to care for critically ill patients.

Floor months: same amount of calls/hours/days off. Learn a lot about how to treat chronic constipation, how to order a diet for diabetic, how to arrange for care in a nursing home.

give me the unit any day!!!

 

[WallowaWanderer]

As an EP, most of your patients will not go to the unit. Having rotated on a floor medicine service will give you some perspective. It's not the sexiest work, but I think it's valuable. On my floor medicine month, even though it wasn't my favorite, I learned a lot of medicine. I saw totally different problems on the floor than I saw in the unit. I was pushed more autonomy-wise because there were more patients to cover per resident/intern. I developed time management and data management skills that will serve me well in the ED. When I did cross cover the clinical questions were real. I evaluated and transfered sick patients to the unit. I communicated more with patients and their families than on any other rotation so far. I learned a ton from my senior resident - we formed a bond and it was a good time. That's not to say that the unit isn't valuable - it's incredibly rewarding and you learn a ton there. Having done both, I can can say that I think learning to practice medicine in both environments is valuable.

I think it's important to get as well rounded education as possible - rotating with Ortho, Ob, Gen Surg, NSurg, Trauma, Medicine, Cards, Peds, Tox, Burn, EMS, Unt, floors, etc can all be valuable experiences. Of course, off service rotations vary greatly in their quality so it's important for the residency to be responsive and make adjustments accordingly. It helps if the EM department has a good relationship with other departments.

If you do a few months of floor medicine/surgery in residency, I don't think it's going to hurt you. I would look for a program that gives you a good balance - not all one thing or exclusively another. Opinions vary.

 

[Koko]

My personal feeling is that unit months are high yield for EM whereas floor months are not nearly as helpful. This was one of the factors that I considered when comparing programs. Particularly in 3 year programs, time is precious and you want to maximize your learning. Also keep in mind that certain off-service rotations exist as political payback between departments: "we'll have our EM residents work your medicine floor for a month to keep your IM department happy and help staff our ED with your IM residents."

 

[uncwalley]

While I agree that floor months are less useful, they are important in your education as an emergency physician. You need to know what you are asking your consultants to do. It isn't enough to just decide this patient needs to be admitted and make a phone call. If this is all you know, you will find yourself being asked by your consultants, "What am I going to do for this patient?" Having an idea of what goes on upstairs will come in handy. Giving an educated answer to this question usually puts out the fire and may win you some slack for your next soft admit later down the line.

 

[deleted109597]

"What am I going to do for this patient?"

Discharge planning.
As they say, it begins at admission.

I disagree that floor months help make you more rounded. All of us did floor months in medical school. If you didn't, then your medical school failed you. When I have floor medicine, floorish (CICU and floor) cards, 3 months of trauma (split between floor and STICU), and floor OB, I think I got that there are floors, and the people on them hate their jobs. I mean, why can't you make the argument that I need a floor peds month, or a floor neuro, floor ortho, or any other to "see how it is run".
I mean, when you look up the RRC requirements for EM

Adult medical resuscitation
Adult trauma resuscitation
ED Bedside ultrasound
Cardiac pacing
Central venous access
Chest tubes
Procedural sedation
Cricothyrotomy
Disclocation reduction
Intubations
Lumbar Puncture
Pediatric medical resuscitation
Pediatric trauma resuscitation
Pericardiocentesis
Vaginal delivery

I don't see "Nursing home placement", "Forms filled out", or "Hours spent rounding".

And just looking at the myriad of differences in the rotations out there, it seems like some places do things because it has always been done that way, some do it because of political pressure from other programs (if you don't rotate your galley slaves through our rotation, we won't _______), and some just apparently want as little non-EM stuff as possible. I don't pretend to know what is best, but to say an IM floor month is just as good as a MICU month is preposterous. If all it takes is seeing how the floor runs, a week or even a day would be useful. I get 2 days of anesthesia, but 5 weeks of medicine. 2 years from now, I sure will be able to talk to a case manager, but I might not be able to do a difficult airway. Which is more important?

 

[deleted109597]

Aww, killed it.
I'm good at that lately.

 

[EM_Rebuilder]

I will have done 5 unit months: MICU, SICU, NSICU, PICU, MICU @ VA. I also did a floor month in medicine and a floor month in Trauma. We may be adding a 'senior' SICU month...that is up for grabs at the moment.

I'll take the unit any day. I like working where I live (aka, I HATED being on call essentially for the 'whole hospital' on the floor) and I hated dealing with diets, pooping, etc. In the units, my bed is, well, in the unit!

My favorite part of the unit was a really sick patient coming in or someone crashing. Boatloads of procedures in the unit (PICU right now... LP tonight and an intubation earlier). Less BS overall....

I agree that one floor month is useful...a rite of passage and to 'know' what those cranky IMers have to deal with on your 'soft admit'... I think for EM, what to learn on a floor month are the social issues much more than 'medicine'....

I am at a 2,3,4 with a EM transitional year so our training tends to be heavier on ICUs (better?...ouch, can of worms) than most typical 1,2,3's. I would not expect any 1,2,3 to have 5 (possibly 6) ICU months.

 

[uncwalley]

Actually, I imagine most 1-3's have 5 ICU months, 2 trauma, 2 MICU, 1 or 2 PICU. We tend to not have much elective time though.

 

[Station51]

I think all the talk of more ICU months is a little preposterous, too. If you have enough procedures and critical patients in the ED, why is there a need to constantly do unit rotations? LAC-USC (2-4 program) only has 2 unit rotations and I doubt anyone would say their program is weak because it only has 2 unit rotations. I'm at a 1-3 program and we have 4 unit months and a neat ED-critical care rotation and I think it works out great (and we still have 3 months of elective). To the med students/applicants, you just gotta ask yourself if the time investment on these unit months is worth it for whatever particular program you're looking at.

 

[Koko]

We are a 1,2,3, with 5 ICU months and 2 electives. Not sure how many other 1,2,3 pgms have 5 units months though. Back when I was looking at pgms as an applicant, it was very unusual to see a 1,2,3 with 5 unit months and no floor scut. Personally I saw enough of the floors as a med student to sympathize, understand the nature of the care provided and realize that I had no interest in toiling on the floors. But that's the beauty of EM residency: you can find a program that suits you given the variety out there.

 

[turtle md]

Floor month = EM-reaffirmation month...

A waste of time. We finally got our program to get rid of it in exchange for another MICU month.