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The EM Mentoring Thread

Discussion in 'Emergency Medicine' started by Graylin, Apr 8, 2007.

  1. Graylin

    Graylin SDN Mentor
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    Welcome! I'm an Emergency Medicine Physician. I have and continue to participate in interviews/rankings/etc and work closely with residency development issues.

    The EM forum is now open!


    Questions for Residents, Physicians, and other Professional Mentors

    1. What do you enjoy most about your specialty?
    Emergency Medicine is a fast paced field that touches almost all specialties. I love the pace, the diversity and the team work that happens in the ED. Patients come in and you never know what they will have. Shift work is great as well. Its a nice lifestyle as well.

    2. Is there anything you dislike about your specialty?
    Shift work has many good things but it does mean that you work a varied scedule, including nights.

    3. How many years of post-graduate training does your specialty require?
    EM is a little odd in that there are 3 year programs, 4 year programs and a few 3 year programs that also require an extra one year internship. In essence, it is 3 or 4 years depending on where you apply.

    4. What is a typical schedule like for your specialty? Are the hours/shifts flexible?
    There is no typical scedule in EM. You work shifts (anywhere from 8-12 depending on where you go). Most attendings work about 35 hours a week.

    5. Where do you see your specialty going in five years?
    EM is not going anywhere. Its a growing field with plenty of job security.
     
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  3. Graylin

    Graylin SDN Mentor
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    Hello everyone. As there is some overlap I am going to try and answser all of the proposed questions in one post. (keep in mind there are no absolute answers to this. These are my opinions based on my own personal experience).


    I'll start with the easiest.

    Why I love EM:

    EM is a great field. Most people love it, who have done residency in EM. (go check out the EM forum and search 'burn-out', its addressed extensively) I have yet to come across people who advise 'don't do it' (this might be because I am in a highly competitive city and in academics). Like *all* fields of medicine, you must like what you are doing and realize no field is perfect.

    What I love about it? My patients are undifferentiated... They have not come to me with partial work ups. I am starting from scratch and that appeals to me. I was also one of those people who liked something about every rotation but nothing enough to want to do that field exclusive of all others. EM is great for that. I get to do OB/gyn, ortho, medicine, cards, ID, ICU, peds, derm, fp, trauma, anesthesia, etc. I like the pace. Its often fast paced and I like to have several patients running at one time. I like the lifestyle- the fact taht my pager is buried in a drawer somewhere. I like shift work as it allows me to spend time with my family and do many other things. I can leave for a month and it has little effect on my 'patients'. The downsides? I do have to work some nights, some holidays. You don't 'know your patients for life' but for me, this wasn't as big of a deal. (and you do get 'regulars' trust me!).

    Regarding what your own institution is like: you have to look at your EM profile: are they EM residency trained? in general, non EM trained EMP's often work more on the consultant end. However, in my institution, this is definitely not the case. We don't consult until we are pretty much done with the work up (ie appy's get called once we have diagnosed it and are ready to go to the OR; Ectopics are consulted once we have verified that there is no IUP on u/s etc; traumas are run by us, etc etc). If you feel you aren't getting a good feel of EM from your school, try looking at another institution, one with residents.

    Regarding DO applicants
    My program treats them pretty much the same.... However, not all programs do. some are DO friendly, others are not. Look in the EM forum, there are a number of DO's there and they have addressed this the past couple of years. (search DO applicants)

    Regarding application issues for residency

    There are no set answers for this. Numbers don't answer everything. But they also don't hurt. So you want to do well in your basics and get good evals in your third year. Strong LOR's. You want to show your interest in EM: student EM group, EMRA, etc. Research doesn't hurt but you should only do it if you are interested in it. Cultivate, to some degree, your non-medical interests.
     
  4. WorkinEM

    WorkinEM Emergency Physician
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    Not silly at all. EM is actually more complicated on this front than other specialties because there are several organizations and some of them disagree with each other on their core principles.

    ACEP (the American College of Emergency Physicians) and its junior organization EMRA (the Emergency Medicine Residents Association) form the largest EM advocacy body. By joining EMRA you are de facto in ACEP. They discount dues for students. By being in ACEP you get Annals of Emergency Medicine which is one of the top journals in the field. You will also be able to attend all of the ACEP conferences and events.
    http://www.acep.org

    AAEM (the American Academy of Emergency Medicine) was formed around the belief that the corporate practice of EM (a practice set up where the docs work for a corporation that holds the contract with the hospital rather than contracting directly with the hospital) is ruining Emergency Medicine. It tends to be more concerned with practice structure issues than ACEP. It also believes that ACEP's leadership is biased toward corporate medicine, a claim that may be valid. AAEM discounts student memberships as well and you get the Journal of Emergency Medicine.
    http://www.aaem.org

    SAEM (the Society of Academic Emergency Medicine) is a body dedicated to emergency medical research. It is a very important organization for the academic faculty you will encounter as a student and a resident. Knowing what's going on in SAEM would help you to converse intelligently with these docs. Its journal is Academic Emergency Medicine.
    http://www.saem.org
     
  5. Graylin

    Graylin SDN Mentor
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    The first step I would take is to meander down to the EM forum and search. There is a sticky on residency review. You can also search for 'best residency' (don't make a post, you might get McFattied). You can also search for residency reviews on www.scutwork.com

    In essence, what you will get is that there are no 'best residencies' in EM. The RRC keeps a tight reign on programs. If you want to be in NYC or the east coast, then these are goign to be the best programs for you.

    Regarding your dean, my initial guess is going to be that she is not in EM. Some of the oldest (and first) residency programs started in NYC. There are lots of new programs across the country. In NYC and the east coast, there is a mix of old and new. The programs in the east coast are excellent. If that is where you want to be, then go for it. There are great programs all across the country and what you have to do is figure out where is going to be a good fit for you.
     
  6. Graylin

    Graylin SDN Mentor
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    They will all serve you well. Naturally, doing a rotation at the program you want/like the most will be best because they will have a 'first hand' look at you. This can be a double edged sword but for most people it works out.

    What people don't realize is that (in NYC) pretty much ANY rotation at ANY program will work well. The PD's all know each other because its a very very small community. They have done residencies together, worked together, etc.

    The MOST IMPORTANT thing to remember is that what serves you best is the quality of your work and your attitude when you are rotating. Not the name of th institution. A mediocre LOR is a mediocre LOR. A great LOR is a great LOR> :)
     
  7. WorkinEM

    WorkinEM Emergency Physician
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    How does getting a job work? Well assuming you have determined what type of job you want (academic vs. community, urban vs. rural, where you want to be geographically) you should start by asking your attendings if they know anyone in that market. You can also ask your PD if there are any grads from your program working in the market. That will give you a place to start. You can also cold call ERs in the area and ask for the directors to call you back so you can ask about jobs. This can be a little intimidating but can get you good info and has little down side. You can also talk to head hunters (people who find docs to fill jobs and get paid to do so) about the market. Finally you can talk to any staffing corporations that might have contracts in your market (for example EmCare, EPMG, etc.)

    A note about headhunters: Be careful. They are paid to get you to sign on the bottom line. This is not the match and they don't care if you are a good "fit." Keep in mind when talking to headhunters that groups don't have to pay headhunters to fill the really attractive, sought after jobs.

    If you want to work in SoCal. The simple answer is yes. You should try to match there if you know you want to work there. Most people wind up working near where they did residency. That being said lots of people don't settle where they trained. If you are sure of where you want to work try to train near there but if you don't you're not locked out forever.

    One thing about job hunting as a doc. Again this isn't the match. It's not designed to be fair. In fact it's not even trying to be fair. It's going to be about who you know and how you interview.
     
  8. Graylin

    Graylin SDN Mentor
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    nev-

    1- EM is somewhat flexible in the sense that we tend to work less hours clinically than most fields. You often don't have a 'fixed' scedule early in your career. In general, you can't pick 'mornings only' or 'afternoon's only'. Because of the variations in practices : group, academic, contract, large corporation, etc, there are variations in scedules. Some people work nights (3 nights a week usually with a larger salary differential). Other people work 'days' which usually involves one or two nights a month and a variety of other shifts. Its kind of one of those things that's hard to explain until you spend some time in the ED. IN essence, its shift work. Many people like this, as there is no 'call' and your shifts are 'fixed'...... This has been awnsered more extensively in the EM forum. You might want to check there as well.

    2- In the ER, we touch on all fields. Many patients are critically ill and thus require ICU management. The ED is the start of critical care. Septic patients, respiratory distress, toxidromes, etc are all initially managed in the ED. Now with many ICU's overflowing, these patients 'board' in ED's, so the EM doctor does much of the managing. Hence why there are now EM Critical Care fellowships. We do a lot of ICU patient management in the ED.

    For gas, we tube LOTS of people. All emergently and using Rapid Sequence Itubation. We don't do the micro-pharm that gas people do, and our airways are much more stressful because we don't rely on the elective/semi-elective nature of the OR. Our patients are almost never npo, and not intubating is not an option.


    Graylin
     
  9. WorkinEM

    WorkinEM Emergency Physician
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    There are academic departments that have "clinical tracks" that are specifically designed to attract faculty who want to teach but don't want to live under the publish or perish system. These tracks tend to demand more shifts than the research positions, which seems fair. Some though limit the clinical staff when it comes to advancement and leadership positions which doesn't seem fair.
    It helps. The more exclusive the program you want the more you need the little helper things on your app like research.
    The academics usually make a little less. 10-25% less seems to be the norm. Bear in mind that they usually have good benefitsm, often have less hours, get to take sabbaticals and so on. I firmly believe that no one should leave the academic vs. private practice up to the money aspect. The money is not different enough while the practice environments are very different.
    No. I don't think it has to do with going academic. I think it has to do with do you ever want to practice internal medicine. If you do then go for it. If you just want it as a stripe on your sleeve to get an academic EM job I'd skip it. There are other fellowships that will help you more if your interest is academic EM like Peds EM and Tox.
     
  10. WorkinEM

    WorkinEM Emergency Physician
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    Good question. Your safest bet would be to do EM related research. That said I think that a project you are really excited about and interested in will serve you well in EM residency interviews. That excitement will likely come across and that type of enthusiasm will look good. You also need to keep in mind that EM is made up of pretty eclectic people and many will appreciate some diversity in your academic background. There are also getting to be more and more public health types (MPH and just interested) in EM. I say if you have a unique opportunity to do a project that excites you go for it.
     
  11. WorkinEM

    WorkinEM Emergency Physician
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    Most full time EPs work ~120 to 160 hours a month. There are lots of docs who work less for family reasons, etc. and make less money. There are also lots of EPs who work more (I know some who work 180-200/ mo) because they need the money or they work like that for 2 months and then take a month off. In my group the requirement to be considered full time is at least 120/ month and most average in the 140s.

    The length of shift you work is very group/site dependent. In my group there are 8s, 8.5s, 9s, 10s and one 11.5 hr shift. These are at different times of day and at different hospitals. We set up the coverage to maintain adaquate staffing at that particular ED. Many groups work 12s and many work 8s.

    As a rule that fits with the national averages expect to work 140 to 150 hours per month broken up into what ever shift system the group has, eg. 12 12s, 15 10s, 18 8s, 75 2s and so on;) .
     
  12. WorkinEM

    WorkinEM Emergency Physician
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    Slinkeyooo

    I noticed you did post over on the EM board about DO EM residencies. I also noticed it met with mixed results.

    Just a note about the EM board. Any mention of the "best" EM residencies always generates flames for several reasons. It's been beaten to death and it assumes that if there are the "best" residencies there are also the worst. EM, possible more than any other specialty, has pretty good training across the board. Anyway, that's why your post was answered the way it was.

    About your question, the main reason the DO residencies are distributed the way they are is that they tended to be near strong osteopathic schools. They are absent or scarce from many large metro areas because they were shut out for many years.

    I don't know about expansion plans. You might try posting on the EM board with a question like "Does anyone know of any planned new DO programs?" or similar. A direct, limited scope question like that tends to get better responses.
     
  13. WorkinEM

    WorkinEM Emergency Physician
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    I would keep doing what you are doing. UCD has an Australian EP on faculty. You might ask the coordinator there if you can talk to her. She would be able to shed additional light on the situation.
     
  14. WorkinEM

    WorkinEM Emergency Physician
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    I assume this was a med school interview. There are a lot of people out there who don't like Emergency Physicians. We call them at 2am with emergencies. We ride them to actually do the right thing for patients. They perceive us as having an easy lifestyle. Med school interviews are often conducted by PhDs who have even less knowledge of EPs although they often have less animosity.

    Here's what I'd say about your interviewer. You had the bad luck of encountering someone with an axe to grind against EM. To keep this in perspective you could just as easily have run into someone who hates surgeons, radiologists, people from Oregon, guys who wear loafers and so on. I would not try to hide your interests at interviews. You should convey that you have an open mind and that while you are interested you know that many people change their minds during med school and that you are open to that. If the interviewer is being less than professional about EM or whatever just emphasize that you are open to all specialties and are looking forward to the experience you'll gain as a med student. If they throw out a barb and change the subject let them and you stay professional.
     
  15. aVR

    aVR DO EM Resident

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    I've been asked to help out with some of the DO EM questions since I'm at an osteopathic EM residency. I'll see what I can do. :)

    As someone else mentioned earlier, the DO programs tend to be affiliated with and located near DO schools, hence a large # of programs in Michigan, Ohio, New Jersey, and Pennsylvania. California isn't exactly a hotbed of osteopathic residencies in general, even though there are 2 DO schools. I'm not sure how many of the residencies are actually in truly rural areas, although some are in smaller cities.

    I've heard that there are a couple of new residencies in the works, but I don't know the specifics.
     
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  17. Graylin

    Graylin SDN Mentor
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    Great questions. Traumas and notifications can be very crazy. The major pitfall and frustration is 'to many cooks in the kitchen'. We have very strict roles of who is allow to speak that we implimented about a year ago, to help streamline this (keeping the paramedics from having to give report to a nurse, md, resident etc over and over). So, now, we clearly id who is the senior resident adn all communication goes through him/her. as an attending, if EMS tries to give me report, I direct them to please speak to the senior resident. this streamlines it and makes it easy for every one to hear and important details not to get lost.

    Field reports are very important. Nothing frustrates me more when a sick patient comes in (but not a 'notification') and EMS is no where to be found. But it happens and we move on.. :)
     
  18. Graylin

    Graylin SDN Mentor
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    this was a very hard year in the match and I empathize with you. It is difficult to give specific direction on what to do, as each case is specific. however, the first thing I would do is speak with your EM advisor to see if you can sort out what your 'weaknesses' or 'areas of possible improvement' might be and focus on those. The other thing to look at is try and figure out if you applied appropriately. I believe that everyone should have a three tiered application process: a few 'dream' programs ('outta your league'), a good chunk of 'appropriate competitiveness' programs and a few 'fall backs'....

    Transferring is tough. You can try adn scramble into a transitional but I wouldn't run into any program and then try to transfer... it makes things difficult etc.

    I hope that helps!
     
  19. Graylin

    Graylin SDN Mentor
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    As WorkinEM said, many places have clinical tracts... It is important however, if you want one of these positions to have a strong CV coming out of residencies, evidence that you like to teach, work with others, etc. We have plenty of EMP's in our academic institution who do not have research on thier agenda at all. However, almost all of them have some area of specialty: ems, disaster, teaching, trauma, cqi, etc etc.
    Again, doesn't hurt but only do it if you love it. If you don't, it shows. Instead, spend some time doing something EM related that you do love. It will show when you talk about it.
    ditto WorkinEM
    Depends on why you are doing it. most people end up doing one or the other.
     
  20. beyond all hope

    beyond all hope Senior Member

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    I am also an academic EM doc in NYC.

    I think it's great that there are forums where students can reach out to those of us who've been through the process. I'm a recent residency grad and one of my goals is to make the process of training more humane to med students and residents.

    Any questions please look through the FAQs and search the archives first, then feel free to PM me.
     
  21. Graylin

    Graylin SDN Mentor
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    I don't really find this to be a big issue. Its part of medicine in general. rapport can still be established even though you don't have continuity. If you let fear of lawsuits drive which field you go into, you will end up not happy in your job. Risk management, good practices, etc can reduce your chance of lawsuits. It is also important to dissect the #'s: BCEM (EM residency trained) vs non-EM. There are still tons of ED's that are staffed by non-EM people.

    I am not sure I really have an opinion one way or the other. I, personally, wonder about the utility. The IM/EM people I know, end up practicing one or the other. There is a complete myth that you can 'switch' 20 years down teh road. (do a search on burn out in the EM forum. its adressed extensively). That said, they are out there. I guess you just have to decide if its right for you. No one is going to say you suck as an EP because you are double boarded..... I would rather (and did) spend the extra years doing a fellowship in an EM related field but, I love EM.
    Depends on who you talk to. people at 4 year programs are going to tell you 4 is best. People at 3's are going to tell you 3. This has also been adressed alot in the EM forum. Try a search there. You can also look at both sides of the argument at www.emra.org. They have some info posted up about it. In essence, its a personal decision. I went three year.
    You are expected to make mistakes as a third year MS. I would recommend working with an attending. You will get good teaching, more procedures and also will develop a relationship with someone who can write you a LOR. That said, if you have no idea what a true ER looks like (one with residents) it doesn't hurt. Sometimes the private/communities can give you a more biased look at EM.

    Your welcome! Hope that helps
     
  22. WorkinEM

    WorkinEM Emergency Physician
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    You would not be the first person to start interviews with only one EM block. You could try to assemble some additional thing like research and so on to augment your app. This is all far enough away that you have time to create some extras. Find an EM mentor at your school to help you.

    Now, if you really want the extra degree go for it. It won't hurt you and it sounds like you are interested in it. But don't do it just to fill time.
     
  23. WorkinEM

    WorkinEM Emergency Physician
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    You should seek out on of the EM attendings at your school to be your mentor. You should see if your school has an EM interest group and join it if they do. If not think of starting one. Join EMRA or AAEM (see post above). Far and away the most important thing is to try to find an EM mentor. You can do this several ways. You can go down to the ED and ask who ever is on if there are any EPs who would be willing to help you out (explain your interest, etc.). You can find out who oversees the student rotations in your ED and contact that person about coat tailing and mentors. It probably won't be the first time its come up. You can talk to your faculty advisor and see if they can suggest any inroads. Good luck?
     
  24. Graylin

    Graylin SDN Mentor
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    I also went to a school that did not have an EM residency. However, this does not condemn you to not being around EM academic individuals. Nor does it mean you can't find a way to EM. (I wasn't even thinking about EM until the end of my third year). I second what WorkinEm said: get an EM mentor! You will want to find some attending EM's in your home institution and work on developing a mentoring relationship. I would also recommend joining EMRA. There is also a virtual EM mentor from SAEM, designed specifically for individuals like yourself. Even in med schools where there are no residencies, there is still often an EM interest group. Try and get involved. Stay involved on the board here as well, in the EM forum. Lots of great advice and friendly relationships.

    Best of luck!
     
  25. Dr. Dukes

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    How do the clinical tracks work? It is my understanding that "research tracks" have pretty obvious benchmarks (X papers and a reputation gets you Associate Prof, Y papers gets you full Prof...). How does it work for clinical tracks? Do you have to be involved in residency education or EMS or something, or do you get credit for simply (not simply) being a good doc?

    Thanks for all your great answers!
     
  26. Graylin

    Graylin SDN Mentor
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    I am not really sure what your question is. Are you uncertain about deciding between ER and trauma surgery?

    I would search the EM forum. It has been adressed rather extensively as its not an uncommon dilemna. Surgery adn EM are very different. Tehre are overlaps.

    In terms of doing away rotations, that is a great idea. If you do well on your step exams, do well on your rotations, get solid LOR's, you may have a harder time but not an impossible one.
     
  27. Graylin

    Graylin SDN Mentor
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    In general, most peple will say that it is better to do EM and then a peds fellowship. There are two reasons: time- its two years of fellowship if you come out from adult em program.

    two- pay. When you work as an adult-peds EM person, you can negotiate part of your salary at an adult pay, which tends to be slightly higher than peds EM pay.


    You have to ask yourself as well though, do you only want to work peds or do you want the option to also work in the adult ED.
     
  28. Graylin

    Graylin SDN Mentor
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    I am not sure why you think it might be harder to move back. In reality, both are about as equally expensive. California is incredibly difficult to match into. You are definately in a difficult position. I can tell you that I would probably go for more programs. Many in NYC have subsidized housing. One of my close friends has done residency in NYC and is moving to the bay area.

    The problem with staying in california, is that ou might end up having to wait a year and re-enter the match or scramble and end up seperate.

    I can't really tell you what is best. There really are no gaurantees in the match.

    NYC is no more expensive than the bay area.
     
  29. WorkinEM

    WorkinEM Emergency Physician
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    We use PAs. Our PAs get flat salary and the supervising docs get the patient billing. Other places do it differently to incentivise the PAs to see more patients. Our program has every patient get seen by the supervisory doc at some point in their ED stay. Other places don't but then you can only bill for the PA visit which is about 70% of a doc visit.

    Groups change what they do based on their volume, staffing and payor mix.
     
  30. WorkinEM

    WorkinEM Emergency Physician
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    1. No don't forget everything, build on it. I found that my EMT background allowed me to be better at codes and sick patients early on as I didn't get overwhelmed. You will be able to revert to ABC and keep your head.
    2. Go into either but don't make the decision based on the burnout issue. If you think you'll be happy in EM you will be less likely to burnout. Much of the old burnout mantra was based on non EM trained docs who wound up in EM for reasons other than love of the field.
    3. Usually. There are situations where you pay your own but the majority of jobs pay your med mal. Those that don't pay you more cash to buy your own. If they didn't they wouldn't be competitive.
    4. You can do 3 or 4 years of post grad training to do EM. The majority of EM residencies are 3 year.
    5. See above and see the voluminous threads about burnout on the EM forum.
     
  31. WorkinEM

    WorkinEM Emergency Physician
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    Good Questions. I hate the useless workups on people who are not really sick, the people who use the ER as primary care, the people who use the ER because their outpatient workup wasn't happening fast enough and the adversarial and defensive environment that the med mal crisis puts us in.

    Some things that are more EP specific that don't get talked about too much are the PMD dumps when the patient is HMO, uninsured or if they're just complicated and in clinic at 4:30pm.

    One thing that has had almost no time on SDN is the fact that as "contract docs" EPs are frequently dumped on by their hospitals. Gas, Rads and Path sometimes get caught in this as well. The issue is that "contract docs" are granted access to the ED (or OR and OR specimens) by the hospital. The hospitals can threaten the contract if you're not willing to do what they want. Contract docs don't have patient panels and can't threaten to refer their patients elsewhere.

    A good example is the problem we're having now. CMS has instituted these problematic "core measures" we have to do including ensuring that every inpatient over 65 gets a pneumovax shot. This has absolutely nothing to do with Emergency Medicine. However our hospital has told us that we are expected to eval the pts and administer the vaccine to appropriate patients. The fact is that they can't force the admitting docs to do this because if they play too rough the docs will just send their paying patients to another hospital. They can force us to do it by threatening our contract. If we don't do it they'll find someone who will.
     
  32. Graylin

    Graylin SDN Mentor
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    I'll weigh in here as well. No field of specialty is perfect. In all honesty, there is very little that I hate. But I do hate working overnights. Thankfully, I don't have to do to many of them, and I consider it a small price for all the other things I love.

    And due to national nursing shortages, I hate that my ED is often short staffed. between that and national health care budgets and cuts, I hate that I can't give my patients the best care they deserve.
     
  33. WorkinEM

    WorkinEM Emergency Physician
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    Shadowing for premeds is a tricky topic. You really don't know enough to be involved in the medicine of what's going on. For example it would be a waste of time for the doc to spend any time going over an EKG with a premed. Usually the reason premeds want to do it is to secure resume points that show interest and commitment and that's fine. Premeds often pick the ED for shadowing because there are often volunteer programs and it has the reputation of being exciting.

    Given that here are my recommendations for shadowing:
    -I suggest not trying to go for a whole shift. You'll get more out of going for 3-4 hours segments. Try to go at different times of the night and day to get a feel for what's going on at different times.
    -Ask questions but don't feel like you have to. Premeds frequently ask things that get a sideways glance because they don't know any better. I have been asked if I have a "real" job outside the ER and if I'm still a resident (because the student had been told by her doctor dad that residents staffed the ERs back when he was a student).
    Good questions usually involve haw the ER works like what does a charge nurse do and how patient flow works. One good question is how the ED recognizes sick patients vs. non-sick patients.
     
  34. Graylin

    Graylin SDN Mentor
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    We have a lot of premeds in our department but that is because we have both a strong volunteer program associated with an undergrad university or two, and we have a research associate program. So, we have tons of them. The ED is a fun and exciting place to be. The one thing to realize is that it is a unique field. The vast majority of medicine does not work or think like the ED. So, although I love the ED, I often give people a word of caution: most of medicine isn't like the ED. If you want a more traditional look at medicine, find a clinic to work in.

    Having said that, nothing beats the ED. Asking questions and being interested is good. You just don't want to cross the line to being a pest. Asking questions when the EMP is knee deep in a code or buried under patients isn't the best time. Just relax, dress professionally, take it seriously but have fun. Easier said than done. :)
     
  35. Graylin

    Graylin SDN Mentor
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    You are so far away from deciding, that an advice offered is likely to be incredibly invalid in a few years.

    As it stands, yes, there are many EM docs who work in the ICU. You can sit for the European critical care boards after a critical care fellowship. There is a huge shortage of ICUdocs and there is a push to make EM people eligable for the american boards. Even without it, I don't know of anyone who has done the EM/CC fellowship that hasn't been able to work.

    So, really, I would just focus on doing well in medical school, maybe getting a little research under your belt. Browse both the EM forum and the Critical Care forum, there is good stuff there. :)
     
  36. Graylin

    Graylin SDN Mentor
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    Micheal-

    First off, realize that internship is the first year of your residency. Its a holdover term from when MD's did a seperate year prior to ever doing a residency. Your first year of residency, regardless of specialty, or location is always called internship. Some specialties require a 'transitional' internship year where you do one year of general stuff as an intern and then start your 'formal' residency.

    Fellowship is post-residency training. For EM, it is a little different because you tend to practice as an attending part time while you are pursuing your fellowship. SAEM maintains a list of fellowships at http://www.saem.org/SAEMDNN/Default.aspx?tabid=382. You can see what types of things people do.

    There are pros and cons to doing fellowship. It delays your financial earnings and is a lot of work. In essence, you must love what you are doing. It makes you more competitive for academic positions but takes more time and work. Its a very personal decision. The key to doing a fellowship is to love what you will be working in. If you don't, then don't bother doing one.
     
  37. WorkinEM

    WorkinEM Emergency Physician
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    I totally agree. One thing about EM fellowships that's different than other specialties is they don't tend to make you lots of extra $$. A surgeon who goes cardiothoracic will make significantly more money than a general surgeon but a toxicologist won't make that much more than a regular EP. The closest thing to a selfish reason for people to do fellowships is to make them more attractive to academic centers but really you do your fellowship for love, not money.
     
  38. Graylin

    Graylin SDN Mentor
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    Unfortunately, there are never an hard and fast rules with the match. This was a really tough year, for some reason. Trying to give an all standing awnser as to why you didn't match is kind of like trying to predict using a crystal ball. So many variables come into play.

    PD's know it was a rough year. A year of surgery under your belt will be a good thing. You will need to get some new LOR's that reflect your work as a PGY1.

    You also probably need to speak to your EM advisor about why you didn't match- someone who knows your 'whole file'. While your board score is a little low, you can't pin it all on that- especially given that you interviewed alot.

    You can't 'mess up the match' by ranking your dream programs high. Its geared to benefit the applicant. If you don't match at your #1, then the match seeks your second, etc. Other programs don't know your match and you can't screw it up by not ranking where you want to go first. This is why consistantly the advice is given to always rank programs in the order you want them.

    You need to take a strong look at your entire application: scores, academic standing, research, extra-curricular activities, personal statement, etc. Look at where you applied and make sure you have an even spread of 'dreams', 'competitive' and 'less competative' for you.

    try and figure out those things that you can actually do something about. And realize it was a tough tough year. Best of luck.
     
  39. Graylin

    Graylin SDN Mentor
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    Before I tell you my opinion, I just want to state the obvious. This is an incredibly personal decision to make. Only you can decide what is best for you. Now, with that stated, I'll be happy to give you my opinion.

    I am a gigantic believer in the 'happiness' issue. It is often neglected for various reasons: percieved prestige, finances, etc. However, I believe it to be one of the most important issues. You are about to embark on an incredibly difficult, time consuming, stressful journey that has amazing rewards at the end. But everyone, at some point (and often at many points) will question if the journey is worth it. Anyone who says otherwise is selling you a bridge. Now, with that said, I believe it to be vital to maximize the opportunity of being happy. Your happiness in medical school will make you a better resident applicant. Your happiness as a resident will make you a better applicant for jobs. I believe this to be true because if you are happy, you are more inclined to do extra things, to be motivated, to work better with others.

    Debt, certainly, is something to consider. But although to the novice, 130K seems like alot, it really, in the grand scheme of your life as a physician, it is not. If having the extra debt is going to make you a miserable person, that is another story.

    the EM market is good. period. It will stay good. NYC is more competitve then it used to be. But being a happy productive med student and then resident, will get you far. Paying off an additional 100K is not going to be that much of an issue. I know that is hard to believe but its true. And your overall happiness, is worth it, in my opinion.

    Hope that helps! good luck:)
     
  40. EctopicFetus

    EctopicFetus Keeping it funky enough

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    Agreed and if you really think about it, if you live your first attending year somewhere between being a resident (45K) and being an attending (185k, for example) living at 115K would allow you to be comfortable and then after taxes you would have 40-50K and that could really pay off debt if it isnt in the sub 3-4% range. Your overall happiness is really important.

    I dont know what level of training many of you are in but keep in mind that you will (and I have) seen people who enter highly competetive fields because they didnt want to waste their good board scores and they are miserable. Find a program/med school/ career that will keep you entertained and happy.
     
  41. wook

    wook Just a hairy situation
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    :thumbup:


    Wook
     
  42. WorkinEM

    WorkinEM Emergency Physician
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    These are pretty broad questions so the answers will be broad as well.

    Emergency Physicians (EPs) see all manner of patients who come to the Emergency Department either throught the front desk or by ambulance. Some hospitals segregate trauma and pediatrics but as a specialty EPs are trained to stabilize and treat everything.

    Most EPs work 120 to 160 hours per month. This is broken up into shifts that usually are between 8 and 12 hours long. Most EPs work a mix of days, evenings, nights and weekends.

    If you work in an academic center you will likely have teaching and research commitments. Some academic groups offer "clinical tracks" where you exchange added teaching and clinical time for research.

    Do you have to do an Emergency Medicine residency to work in an ED? That's a complex question because of some political battles that are being fought right now. The basic answer is yes, if you want to work in an ED you have to do an EM residency. The confounding factor is that there are some EDs out there (especially in rural areas) that will hire you without an EM residency. But to be a really viable candidate for the majority of EM jobs you must have done an EM residency.
     
  43. WorkinEM

    WorkinEM Emergency Physician
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    That’s an excellent question and a tough spot to be in. I will say that I’m curious who is saying that the residents are weak. The only real gauge for the quality of a program is the competence of its graduates. If those saying the program is weak are colleagues and directors of the graduates I’d be concerned. If it’s coming for attendings in other departments like medicine and surgery I’d give it less credence. Those complaints tend to be more about residents who “Don’t know how we do it on my service.” or how “They really screwed up that one patient they called us to consult on.” They tend to be more fish bowl gripes that real criticisms about the resident’s capabilities as an Emergency Physician.



    I disagree. The med school has so much less to do with a resident’s strength than the residency program.



    That’s the problem. You have to take into account how the person making the criticism is arriving at the strong vs. weak decision. The majority of times I’ve seen residents called weak it had to do with some personal disagreement.

    That’s a great question. If I could totally answer it we could do away with the inservice and the boards.

    I will say that you should watch the seniors. Are they comfortable with the basics like intubation, EKGs, critical patients, lines and so on? Do they manage the ED as a whole by prioritizing patients and making sure the flow flows? Are they able to resolve disputes with consultants?

    Get the numbers of some recent grads. Ask them how comfortable they were when they got out. Everyone is uncomfortable when they’re fresh out but were they able to function and work through it like most or not.

    I can’t stress enough that the only real measure of a residency program is the competence of its graduates. Try to figure our if the criticisms are based on that or on some other issue.
     
  44. Graylin

    Graylin SDN Mentor
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    I don't have a lot to add to what WorkinEM said. It really is contextual. Who is saying 'weak'?

    Strength in residency has almost nothing to do with medical school and everything to do with residency. I think the advice to talk to graduates is crucial. :)

    Basically, ditto what he said. :D
     
  45. WorkinEM

    WorkinEM Emergency Physician
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    Medical schools don't take students for specific specialties. If you want to do EM you have to get into medical school and then, in your fourth year, you apply to residencies in whatever specialty you choose.

    If you're asking about which med schools might accept someone with poor grades in college you might do better addressing your question to the pre med forums.

    If you're asking which EM residencies accept candidates with poor grades that's a tough one. EM is pretty competitive these days so if you have some glaring defencies in your med school or board records getting into an EM residency will be harder.
     
  46. Graylin

    Graylin SDN Mentor
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    '
    This is a somewhat controversial topic. There are one or two fellowships for FP doctors to do. However, you are not eligable to sit for the Emergency Medicine boards. You can not become board certified in EM without doing an EM residency.

    There are small ER's in rural locations that will hire FP's to work in the ED. In the legal area, this may become harder and harder.

    You might try adressing this in the FP forum where people have more experience as FP's. You can also search in the EM forum as there are several threads that discuss this.
     
  47. WorkinEM

    WorkinEM Emergency Physician
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    The "fellowship" that FPs can do does not lead to board certification in Emergency Medicine by the American Board of Emergency Medicine or any board recognized by the American Board of Medical Specialties.

    There are non-EM trained docs who work in EDs. These are predominantly rural or otherwise underserved EDs that have to take what they can get. Docs with these "fellowships" or docs who are "board certified" by unrecognized orginizations like the American Board of Medical Specialists are not competitive for the vast majority of jobs in Emergency Medicine.

    There have been many, often heated, discussions of this issue on the EM and FP forums. Here's an example:
    http://forums.studentdoctor.net/showthread.php?t=381970&highlight=board+certification

    Here are some other useful sources of primary info to give you an idea about the controversy:

    http://www.abpsga.org/index.html

    http://www.acep.org/webportal/membercenter/periodicals/emtoday/2005/EMTodayJuly112005/CertificationIssueRekindledinFlorida.htm

    http://www.aaem.org/positionstatements/abdm.php

    http://www.em-news.com/pt/re/emmednews/fulltext.00132981-200703000-00001.htm;jsessionid=GMjGYm6164hctffLLKnHNvVCTcGhN7SbwQ5LvL14vG9JpDyyg4sd!1888299356!-949856144!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

    http://www.em-news.com/pt/re/emmednews/fulltext.00132981-200611000-00001.htm;jsessionid=GMjGYm6164hctffLLKnHNvVCTcGhN7SbwQ5LvL14vG9JpDyyg4sd!1888299356!-949856144!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

    BTW Greylin and I answered this at the exact same time which is why there are 2 replies.
     
  48. emedpa

    emedpa GlobalDoc

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  49. WorkinEM

    WorkinEM Emergency Physician
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    That's a good question. This is actually a version of the old "triage nurse" criticism levied at EPs by the rest of the world. My answer is that it does not bother me in the slightest that I'm not the definitive doc on most of my patient's issues. Most of us in EM joke about having short attention spans and there's some truth to it. We don't generally like working up problems to their conslusions. We like evaluating, stabilizing and dispositioning.

    Even though we are not the definitive docs we are the only docs with the skill set to do what we do. We are ready to deal with anything that rolls in, day after day. And it can be anything. Trauma, peds, OB, burns, psych, tox, anything. I feel that we are the best at emergent airways. In many centers we run all the codes and do all the tubes. We are able to run an ED and prioritize patients and keep the flow going.
     
  50. Graylin

    Graylin SDN Mentor
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    I would argue against these assumptions for a couple of reasons:
    1- No one physician knows everything about a disease or the totality of the mechanism.
    2-It is a rare shift where I don't look up current research in my field. For EM docs, skills must even be finer honed because while I look in EM journals, I also look in cards, ICU, etc journals for my literature. (PICO is my friend) EMP's must be well versed in many areas and thus must draw from many areas of research. If you are an EM doc who just moves through patients, never looking up literature, etc, you are a danger to your patients.
    3. As WorkinEM said, the 'triage' concept is old world and not applicable. Does it bother me to not always now the diagnosis? No, but niether do IM, ICU, etc docs sometimes. It just happens a little more often in the ED.

    Hope that helps!
     
  51. Graylin

    Graylin SDN Mentor
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    Right now, there isn't a shortage of EM docs. Academic positions are more competitive but there isn't a shortage of positions. It really depends on the market. Some are locked very tightly, others are more open. It seems to be in a balance right now, overall. Academics is definately becoming more competitive though and gets more so each year.

    I will be honest, I have definate ideas of where I think health care should be. However, I am not a health care policy person. One of the reasons I particularly like EM is we (I) get to hide behind emtala. I don't think about people's insurance, etc to determine my care. I give the best care and that's it. I know its a little bit of head in the sand, but it was one of the reasons (out of many) that I picked EM. I like caring for all patients, not just the ones that can afford it. :) Maybe someone else can give you a better awnser to this question. :)
     
  52. Graylin

    Graylin SDN Mentor
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    how much research is weighed in is highly dependent on the programs you apply to. Some will weigh it heavily, others not so much. Research never hurts. However, you shouldn't fall into the 'checking boxes' mentality. Do research if you are passionate about it. People who don't love research do crappy research and it shows. Or when you are asked to speak about it, it becomes immediately obvious that you weren't really into it. If you love it, you will find ways to do research. Between your ms years is not the only time.

    If you don't love research, spend your time doing something you love.

    I'm not sure why malpractice is necessary to do research. Even clinical. We have approx 60 research associates every sememster in our ED conducting research and none of them have 'malpractice'. You only need this when you are doing direct patient care.
     

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