The EM Mentoring Thread

[WorkinEM]

I'll be an entering MS1 this fall, and I think it's great they have this forum. I've worked as a "Scribe" the last couple years in Fresno, and have really enjoyed my time working with the ER Docs. I had a couple questions:

1. Is there a shortage of EMP's at academic centers for teaching/research? I'm just curious how competitive the academic environment is.

2. What are your takes on the proposed universal healthcare plans? I'm specifically interested in how a universal plan would affect reimbursement for Emergency docs.

Thanks for your help, I look forward to being a regular reader.

I work for a large corporate EM entity (EmCare) and they firmly believe that we will be looking at an across the board shortage of EPs in the coming decades. Their reasoning is that there is a fairly static number of graduates every year (~1300) and that the attrition from the boomer aged docs leaving will be ~3000/yr for several years. So it's likely that all positions, academic and private practice, will be looking for docs.

Any kind of universal health care will result in lower pay for EPs. If the plans work then they will divert a lot of the primary care type patients to more appropriate venues. If they don't work and start becoming financially insolvent they'll just reduce reimbursements.

Just for the sake of disclosure I'm philosophically opposed to socialized medicine (and socialism in general) but at this point I'd accept it if it really eliminated the med mal issues we have now.

One real concern I have about the logistics of universal care is that when we have rationing people will try to circumvent the rations by going to the ER just like HMO patients do now. Consequently the burden of denying care and explaining why grandpa can't have a CABG when he's 88 will fall to us. Just look at how more and more of the CMS Core Measures issues are being dumped on the ED. The same will happen with any unsavory aspects of universal care.

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[MarzMD]

I am an em pa who works at a busy trauma ctr on the west coast.
The bill for the pa seeing the pt alone is 85% of the md bill.
we are paid hourly plus production bonus. In our system the pa's only present the pts they want to get consults on. our pa group is all very experienced folks with no new grads. most of us have prior experience as paramedics and we are all certed in acls, atls, pals, fccs, and the difficult airway course. we see fast track and moderate acuity(belly pain, bleeding in preganancy, worst h/a ever, etc) types of pts. the docs staff the critical area and see probable mi's, cva's, and multisystem trauma. we see almost everything else. we also run an ed obs unit where the pa's do treadmill screenings on "low risk" chest pain pts. we all do very well salary wise( last yr the pa salary range was 110-160k) but we make the docs significantly more money than it costs to pay our salary and benefits packages. it's a great deal for all of us.

Can anyone comment on the type of salary they have seen while interviewing(particularly non-academic jobs). I have seen surveys, but I tend not to trust them. Plus, I can never figure out if they mean after taxes and malpractice. With PA's making 110-160, EP have to be making a lot more than I have seen quoted on surveys.

 

[WorkinEM]

Can anyone comment on the type of salary they have seen while interviewing(particularly non-academic jobs). I have seen surveys, but I tend not to trust them. Plus, I can never figure out if they mean after taxes and malpractice. With PA's making 110-160, EP have to be making a lot more than I have seen quoted on surveys.

The average in my area (Southwest- LA or SD) is ~$180/hr. That's gross without benefits.

I can't stress enough that to really compare compensation packages you've got to figure out what the benefits are worth and compare apples to apples.

 

[WorkinEM]

hi, thanks for taking your time to mentor. At the risk of this being a "chances" question, I'd like to run my situation by you. I'm an IMG who has fantastic LORs from an EM rotation at a good institution, and am currently doing a peds EM rotation at a good hospital which I'm hoping to get a letter from. CV (resume)-wise, I'd have a ok application with strong extracurriculars (sports, student med journal, a bit of research tho not EM related and without significant pubs). Unfortunately, I wouldn't have a strong USMLE history. My heart's set on EM and I'll be applying in this next cycle, but with EM being so competitive lately, would I just be wasting my time and efforts? should I "settle" for a field in which board scores are a bit more lax?

I suggest applying to EM programs but making sure you have a back up. There are several options. You can apply to a different specialty as well as EM and plan on going that route if EM doesn't work out. You can apply to transitional year programs in a ddition to EM and plan on reapplying as a PGY 2. You can apply to EM only and arrange something else like a research year and apply again. I would say that if you do't get an EM spot 2 years in a row you may want to reevaluate.

 

[leorl]

This is completely off topic (sorry), but Graylin, that is an absolutely adorable avatar. What little creature is that?

 

[Graylin]

hi, thanks for taking your time to mentor. At the risk of this being a "chances" question, I'd like to run my situation by you. I'm an IMG who has fantastic LORs from an EM rotation at a good institution, and am currently doing a peds EM rotation at a good hospital which I'm hoping to get a letter from. CV (resume)-wise, I'd have a ok application with strong extracurriculars (sports, student med journal, a bit of research tho not EM related and without significant pubs). Unfortunately, I wouldn't have a strong USMLE history. My heart's set on EM and I'll be applying in this next cycle, but with EM being so competitive lately, would I just be wasting my time and efforts? should I "settle" for a field in which board scores are a bit more lax?

You shouldn't settle. You need to apply wisely, not exceptionally competitive programs and having a back up is good. like a transitional year.

LOR's and extracurriculars are are good. USMLE's are not as vital (good ones don't hurt.)

 

[Graylin]

Hello,

Thanks in advance for all your help on this forum, it's an invaluable asset.

Could you please comment on the team aspect/nature of emergency medicine and if that drew you towards the field at all? Are there any downsides to this team atmosphere in the ED?

Thanks!

More and more, medicine is becoming a 'team' field. The NIH and the AHRQ are all recognizing that interdisc. approaches are the way to go. This is the way the ED works. Its great. However, becasue you are working with people, well, some people can be hard to work with. In EM, this is often the 'untouched' aspect of training. you MUST learn how to deal effectively with nurses, consults, etc. or your career will be miserable. So its good, but it can be bad. In general, I think its a plus. If you don't like working with others, etc EM is not the place to be.


and my avatar is a sloth... the coolest, cutest animal on the planet.

 

[Graylin]

Thanks for your encouragement, Graylin. Can I get your opinion on what kind of transitional year is better - prelim med or prelim surgery? Some say surgery because once you've done prelim surgery, it proves you're a very hard worker and can handle a very high pressured environment. But some say prelim medicine because you can schedule EM rotations early. Does it matter? Thanks again

As an end sum, it probably doesn't matte much. I think that you can show you are a hard worker on either rotations. Transitionals aren't cake walks. I think you have hit the gist of one over the other. I would probably do a transitional so that you could do EM months and you will still do ICU/wards, etc. all useful in the ED.

Surgery might get you more time in a SICU but in general, you don't do a ton of procedures as a surgical intern. Each has pros and cons and in the end balances out.

 

[WorkinEM]

What do you think the chances are of EM docs being able to be US board certified in intensive care within the next few years?

Good question. I don't know much about how ABEM is moving on this. Greylin? You might also post this question as a new thread on the EM forum. I bet some of the other folks there would have some thoughts.

 

[WorkinEM]

One thing I like about EM is that I am pretty sure I want to do a lot of procedures as an MD or I think I will get bored. Can someone comment on the kinds of procedures an EP will do on a regular basis, and also some not so common procedures that EP's will also have to do? Also, what other specialties where you all thinking about besides EM? I would like to know what other specialties like minded people also thought about while in medical school.

Common EM procedures:
Intubation
Central lines
CPR
Defibrillation/Cardioversion
Wound care, suturing
Fracture/Dislocation reductions
Ultrasound
LPs
Nasal/Otic/Corneal/rectal foreign body removal
Chest tubes
Regional anesthesia- digital blocks to larger eg. axillary blocks
Slit lamp exams
Pelvics
Nasal packing and cautery
I&D of abscesses

Less common ED procedures:
Thoracotomy
DPL
Pericardiocentesis
Births
Cut downs for venous access
Surgical airways - cricothyrotomies, needle crics, etc.

Remember: The worse the patient gets the more the ER doc does.

When I was a med student (note that whenever a statement starts with the phrase "When I was a whatever" it is of dubious value, however, you asked so...) I started out wanting to go EM. I toyed with the idea of surgery for a few weeks in third year but was otherwise EM throughout. I think everyone should look carefully at at least one other specialty just to make sure they are looking at their chosen specialty with enough scrutiney.

If I were going to do any other residency looking back now I'd do gas.

 

[Graylin]

What do you think the chances are of EM docs being able to be US board certified in intensive care within the next few years?

Trying to predict what governing boards will do is like trying to predict who will win the NBA finals at the beginning of the season. (okay, its a lame analogy but I am only 1/4 way into my first coffee)

It will happen. Eventually. When is another question. Currently EM docs who do CC fellowships sit for the European critical care boards. I don't know of any who have had trouble working as an intensivist. There is a huge shortage and most hospitals are just happy to have an intensivist who is trained in it.

There is a critical care thread and this has been asked a number of times in the EM forum. check there for other opinions

 

[Graylin]

Common EM procedures:
Intubation
Central lines
CPR
Defibrillation/Cardioversion
Wound care, suturing
Fracture/Dislocation reductions
Ultrasound
LPs
Nasal/Otic/Corneal/rectal foreign body removal
Chest tubes
Regional anesthesia- digital blocks to larger eg. axillary blocks
Slit lamp exams
Pelvics
Nasal packing and cautery
I&D of abscesses

Less common ED procedures:
Thoracotomy
DPL
Pericardiocentesis
Births
Cut downs for venous access
Surgical airways - cricothyrotomies, needle crics, etc.

Remember: The worse the patient gets the more the ER doc does.

When I was a med student (note that whenever a statement starts with the phrase "When I was a whatever" it is of dubious value, however, you asked so...) I started out wanting to go EM. I toyed with the idea of surgery for a few weeks in third year but was otherwise EM throughout. I think everyone should look carefully at at least one other specialty just to make sure they are looking at their chosen specialty with enough scrutiney.

If I were going to do any other residency looking back now I'd do gas.

When I was a med student (insert WorkinEM's warning), I was decidedly NOT EM oriented. Didn't know much about it and didn't care. I was going to do pediatric rheumatology. Then I considered vascular or trauma surgery. I loved them but hated the lifestyle and dismissed it quickly. I then considered adolescent medicine but I think that was just a momentary psychosis. I liked gyn but hated ob and the life. I really didn't know what I was going to do. Maybe fp. Then a friend recommended EM. And I shadowed one shift and found my place. I love what I do. I thought about urology but at that point, I didn't want to entertain anything else.

I agree. You should keep an open mind. I couldn't figure out why they were making me learn about adults when I was a first and second year. You never know what you are going to fall in love with in medical school.


If I had to do it all over again, I would have found EM earlier.

 

[Graylin]

Hi, I'm beginning medical school next year and my background is in Public Health and HIV. I've searched the forums, but can't find much information on this topic. Is it possible to do an EM residency followed by an Infectious Disease fellowship? In public health, I've heard a lot about people without insurance presenting to the ED with AIDS-related illnesses, tuberculosis, STD's and community acquired MRSA. I'm also interested because of the increasing emphasis being put on emergency rooms as ideal places for HIV screening. Additionally, it was mentioned previously in this discussion that EP's may work in the ICU, an area of the hospital where ID is obviously a concern.

It seems that it would be reasonable to do an EM residency and an ID fellowship. From what I've read though, it seems like most ID fellowship programs want to see an IM residency. Do you know of any EP's who also work in ID?

Thanks!

You can not do an ID fellowship after EM. You can only do it after an IM residency.

depending on what you want to do, EM may be a better field. If you want to manage HIV patients on a daily basis, IM with fellowship is better. We have one faculty member who is IM/ID/EM boarded. He has always done international work and realized during his fellowship that EM was better suited. However, he utilizes all of his training, but that is a very long haul.

There is a lot of publich health work that happens in the ED and many EMPs with MPH's who work in the field. It will really come down to what you love to do.

You could consider a joint IM/EM fellowship with an ID fellowship afterwards.

Most importantly, I would enjoy medical school and keep an open mind.

 

[wook]

Most importantly, I would enjoy medical school and keep an open mind.

 

[Graylin]

I’m really interested in EM, unfortunately my school doesn’t have an EM residency program, and people here aren’t very supportive of the field . I’m at the end of third year and I am planning my EM rotations. My dean told me not to do any with our ED, rather to set up rotations at places with residency programs. Can you advice me on how many rotations I should do, and when they need to be completed (I have requirements in July and August, I have an EM rotation set up for September, I'm trying to change my schedule so I can do another in August, but if not, is October too late?) How many SLOR should I have, and is it okay to use two letters from different attendings in the same program? Thanks!

Definately do two rotations if you can. October is not to late but its close. Its fine to use two letters from different attendings if you don't have any other choice. But having 2 lors from 2 different programs is better. I don't remember anymore what the limit is anymore. It seems like every time I read an application there are more LOR's. I prefer to see a couple of EM ones and one from a non-EM rotation, showing that you can work well with others.

 

[wook]

How many SLOR should I have, and is it okay to use two letters from different attendings in the same program? Thanks!

A point of clarification...when I was a med student I thought a Letter of Recommnedation (LOR) and Standardized Letter of Recommendation (SLOR) were the same thing. In EM, the SLOR is a form that has been created by CORD (Council of Emergency Medicine Residency Directors). This form can be found here...http://www.cordem.org/slor.htm. I share this as I found this information out (I had all my letters of recommendation already) in September/October of the interview season and want to spare folks some excitement during the interview season.


Wook

 

[WorkinEM]

Thanks! I was assuming they were different versions of the same thing. I guess I wasn't the only one here.

A question I've had for a while: is there a place I can view what the different codes mean (like when a paramedic gives you a code green or blue or whatever). Maybe I'm missing it somewhere, but I figured it might be a good thing to know before stepping into the ED. Thanks for your help! (you can always fatty me if necessary ).

Are you talking about in house codes? In house codes (like Code Blue or Code Red) are hospital dependent and mean different things at different places.

Some examples:
Code Blue, Code 99 = cardiac arrest
Code Red = Fire
Code Amber, Code Pink, Code Rainbow = baby abduction
Code Strong, Mister Lift = Lifting help, big patient down
Code Rush, Code Guard, Code Force = Security alert
Code Hydro = bomb threat

Note I'm not making any of those up.

If you're talking about the radio codes that medics and other use like the 10 codes check this link:
http://www.radiolabs.com/police-codes.html

If neither of these cover your question then FMF!

 

[EM2BE]

Are you talking about in house codes? In house codes (like Code Blue or Code Red) are hospital dependent and mean different things at different places.

Some examples:
Code Blue, Code 99 = cardiac arrest
Code Red = Fire
Code Amber, Code Pink, Code Rainbow = baby abduction
Code Strong, Mister Lift = Lifting help, big patient down
Code Rush, Code Guard, Code Force = Security alert
Code Hydro = bomb threat

Note I'm not making any of those up.

If you're talking about the radio codes that medics and other use like the 10 codes check this link:
http://www.radiolabs.com/police-codes.html

If neither of these cover your question then FMF!

Hahaha...I think I found a new way to search for places to do rotations: if they have a code rainbow. I want to just be able to hear it or see it at least one time.

It kind of helps...I was looking for the codes the paramedics report to the ED when bringing patients in. I've heard the colors, just didn't know what goes where (Code green, yellow, orange, black, blue, red, maybe one or two others). Like one I know means crazy/psych patient, one means minor, one means dead...I just didn't know which colors meant what. I guess that was the basis of my question. Is there a simple way to explain the basis of these colors? And yes, I do deserve the FMF for this one, but I just can't seem to find my answer online anywhere...for some reason they just don't want the general public to know when the paramedics are calling them crazy

 

[WorkinEM]

Hahaha...I think I found a new way to search for places to do rotations: if they have a code rainbow. I want to just be able to hear it or see it at least one time.

It kind of helps...I was looking for the codes the paramedics report to the ED when bringing patients in. I've heard the colors, just didn't know what goes where (Code green, yellow, orange, black, blue, red, maybe one or two others). Like one I know means crazy/psych patient, one means minor, one means dead...I just didn't know which colors meant what. I guess that was the basis of my question. Is there a simple way to explain the basis of these colors? And yes, I do deserve the FMF for this one, but I just can't seem to find my answer online anywhere...for some reason they just don't want the general public to know when the paramedics are calling them crazy

I suspect the color codes you're talking about are specific to whereever you are. I have not heard them used any of the places I've been and I've got a ton of EMS experience. Try asking the charge nurse in the ED where these codes are used. If anyone will know it would be them. And the FMcF was only in jest.

 

[WorkinEM]

the most important of these is code brown, you want to rush to help whenever you hear this.....

I stand corrected. That is a universal color code.

 

[Graylin]

I've heard EM Residencies are especially grueling. Is this the case? If so what is the worst part?

Additionally, are there any advantages or disadvantages to doing a 4 year residency versus a 3 year residency?

Thanks guys. I want to add this thread has been very insightful and has put EM as one of my top choices pre-medical school (applying this cycle). Although I realize I'll likely change my mind 100 times, EM never the less is very interesting.

The first thing you should realize is that you should not listen to anything anyone tells you about any specialty except those in it directly. Even EM docs who did residency 10 years ago (unless they are PD's or associated with a residency program) can't really speak to what residency is like now-adays. I completed residency not to long ago. It is not as grueling as some fields. Yes, residency is hard and tiring. However, because of the shift work aspect of EM, its not to bad. The 'worst' months tend to be off-service months. However, due to RRC guidlines, etc, the work week is limited as well as mandated time off. EM is hard because it is significantly different in the approach to patient and in the volume of patients you see per hour. Learning that skill takes time and can be stressful, but any residency is stressful and hard, but very rewarding.

Regarding 3 vs 4 years, this is a long standing arguement. You can read about it here: www.emra.org. You can also search it in the EM forum, which has multiple postings on the exact topic. You will see why some are for, some are against. In essence, there is no one 'right' awnser and there are advantages and disadvantages to each, so that it basically becomes equal when you get down to it. Its a very personal and program specific question, and likewise, awnser.

Regarding being early, there is nothing wrong with being excited about a field. But realize that you should be open to all fields. You never know what you will fall in love with and in truth, although medicine is specialty driven, all fields touch each other and even if you hate one, you should be able to appreciate and recognize the value of others.

 

[Graylin]

Some of the earlier posts give us an idea of what kind of salary we can expect, but it was gross and I am curious as to what we can expect to pay in terms of malpractice, etc. and also if any bonuses are involved. I just need to know so I can start picking out cars and houses. Thank you all for taking the time to mentor us, it is much appreciated!

There is no clear cut awnser to this question, because of the variety of jobs out there. Academic vs democratic group vs independent contractor vs corporate vs per diem. even within each group, there is variation. Many places cover your malpractice, many dont. Same for disability, 401K's, insurance. pure RVU based or base salary plus RVUs.

Unfortunately, you will probably just have to wait and see where you end up taking a job. Plan frugally and everything else is a bonus.

 

[WorkinEM]

A few generalities about compensation (the more correct term for salary).

-The majority of situations pay your malpractice for you. In my area (Southwest) it's about $12 per chart or ~10% of my gross collections.

-I echo Greylin's comments. I will say again that you must (MUST, MUST, MUST) compare apples to apples when you evaluate jobs. A job with high pay and few benefits is likely to be similar to a job with lower pay and good benefits. To make them apples to apples you literally have to get quotes for the benefit products you'd have to buy yourself on the open market (eg, health insurance, disability insurance, etc.) in the area of the job to see what the benefits are really worth.

 

[WorkinEM]

Hi, I'm trying to plan out my schedule for 3rd year. I have one elective in Feb and was wondering if that would be too early to do an EM rotation (and to ask for a LOR). I'd like to save July and Aug of 4th year for away rotations but I don't want to screw myself over at my home program because I wasn't ready. Should I just wait until 4th year to do it? Thanks.

I'd say Feb is fine. It would be ideal if you could do some of your heavy rotations (eg. medicine, surgery) before so you are up to speed on how those services run. Make sure your school will let you do EM as a 3rd year. Some won't.

A word about away rotations. They are great and can really help you if you plan to try for that particular program or can get a letter that helps you out (big name or someone with ties at a place you want to go). However, for the majority of applicants, a solid home EM rotation with a great LOR from your home PD or chair will gie you weight across the board at any program. Just keep that in mind in your planning.

 

[WorkinEM]

Hello. I am starting my first year of medical school this fall. I am interested in EM and I want to shadow an EP for a few days to see if it would interest me further. Would that be a good idea or should i just wait until the EM rotation during 3rd and 4th years?

Thanks for taking the time to answer our questions.

Shadowing is very popular so it can be difficult to find EPs who are willing and not full. Shadowing also tends to be less valuable the earlier you are in your education as you can't appreciate the medical, political (inter-service) or economic issues involved in what's going on.

I suggest leaving the shadowing for later in second year. Right now I suggest joining the EM interest group at your school and joining EMRA which is the Emergency Medicine Resident's Assoc.

http://www.emra.org/index.cfm?FuseAction=Page&PageID=1000000

Be sure that while you nurture your interest in EM you keep an open mind about other specialties. If you find something you like more then great. If you wind up in EM then you'll always know that you gave everything an honest chance.

 

[WorkinEM]

Hello, thanks for answering everyone's questions. I'm an EM resident with an EMS background. One day, when I grow up, I would like to be an EMS director in a large urban setting. Would you mind talking a little about the EMS fellowship? Basically, I'm trying to make the "is it really worth the extra year" decision. Thanks!

Great question. For the lurkers this question is basically asking "What's the advantage to doing a fellowship in a discipline that does NOT give you and additional board certification?" In EM there are some fellowships you can do that will make you eligible to sit for an additional board cert such as toxicology. Others don't, such as EMS or Ultrasound. For more info on EM Fellowships check out:

http://www.saem.org/fellowlist.html

Now, for EMS specifically. I had a similar situation. EMS background, wanted to do EMS direction in the future. So I looked at doing a fellowship. I didn't for various reasons and now I teach Critical Care Nursing for AMR and I'm medical director for a program that teaches EMS courses from EMT-basic through Paramedic and all the merit badges. So it is pretty easy to do as much as you want without the fellowship. Skipping the fellowship is almost always better financially. With loans to pay is tough to sign on for another 1-2 years of servitude. Out of all the medical directors for fire and private agencies I know none were fellowship trained.

So what are the pros for fellowships? I suspect that if you really want to fast track yourself to be a director in a top tier city like New York you would be benefited by doing the fellowship. I also suspect that doing a fellowship in the city you want would be of the most benefit. Another thing about doing a fellowship is it gives you more time to make some tough choices about working private practice vs. academic and what type of setting you like best (community ED vs. big center). Most EMS fellowships have you work shifts in their big center ED during your fellowship time and most people also moonlight at smaller EDs so you'll pick up some diverse experience and get to see where you're most comfortable. Finally, some of the fellowships out there sound really fun. Some give you a Battalion Chief mobile type vehicle and you cruise around and respond to all the big incidents. Others have you ride with supervisors. Most have you doing all the on line med direction while you're on duty. So you get to do some cool stuff in addition to the real guts of the fellowship which is (here's the let down) education, regulation and administration.

One more note. Some EMS fellow ships offer an MPH. My feeling is that if you're going to go for it and you're looking for a top spot in a top city you might as well go the whole way and get the MPH. Again not mandatory but might make sense depending on your situation.

 

[Graylin]

Ok, what better thread to be a FMcFP and stress about my app, right?

I just want confirmation - emergency department is not capitalized and Emergency Medicine is, right?

Also, any tips on personal statements, CVs, and other aspects of the application (pet peeves, etc)? I am trying to polish mine up.

Thanks!

In general, yes. emergency department is not capitalized and EM is.

I can tell you my own pet peeves and opinions with the caveat that they are my own (although our associate PD and PD will concur).

Regarding personal statements: brevity. Remember, we are EM docs. Short, sweet and to the point. None of us can make it through a really long essay. It doesn't mean your experience aren't valid. We just don't have the attention span to read through 100's of these essays.

In general, drawing analogies to the ED are tedious and overdone. (ie: waiting tables, climbing mountains, etc.). Touching stories about that one ED doc, your grandmother, etc also tend to be a little overdone. I tend to pretty much stop reading when I see these things.

On your CV, put all papers, publications, extra curriculars, etc.

Remember, you obviously want to go into EM. You don't need to prove that in your CV or your PS. Put in stuff that will also allow the readers to get some idea of who you are. Yes, you need to check the boxes, but get who you across.


My .02

 

[Graylin]

Thanks. No need to respond, but I felt like replying to some of your points.

I hate long PSs, too and limited myself to 500 words (half of the one page word count). I am at 456 and hopefully I can cut a bit more. I want people to be impressed by my brevity

I did use 3 sentences to draw a few analogies between EM and the lab, only because as a MD-PhD applicant I am relatively rare and frequently interrogated on that point. Tried to avoid being "themey" because it was kind of irritating when I was on an adcom.

My essay is still a little corny so maybe I will trim the "why I love EM" part a bit (had expanded it cause it looked awkward being the shortest paragraph).

Don't completely change your statement. remember, these are just mine and a few select opinions. I think if there are abnormal things they should be addressed. the corny stuff is just my .02.

 

[WorkinEM]

Any thoughts on a US citizen who is a IMG chances on getting into EM?

This question is impossible to answer. Your chances are totally dependent upon all the various elements of your application. It also depends on the competitiveness of the match in any given year. EM is a competitive specialty. There are IMGs who get spots in the match.

The "what are my chances" question is impossible to answer even if we had all your personal stats. It's also of little value to be told that you have a good or bad chance by someone on an internet board who would be guessing at best.

I suggest continuing to try to get the best rotation grades, board scores and LORs you can and then apply based on what you think will make you happy.

 

[Graylin]

I have spent a significant amount of time shadowing residents in the ER as well as volunteering in the ER. I've noticed some really great things and some things I didn't like.

I really like the constantly changing and fast paced environment. You are always busy and you never know what you are going to get. That part of it I absolutely loved.

On the other hand, I felt like the ER physicians weren't really doctors. For the average "headache" type patients, they did some basic tests and sent them home. For anything else, they had to call that patients doctor to figure out what to do. The ER docs spent as much time on the phone with other doctors finding out what they wanted to do than they did actually seeing patients and being doctors.

Just wanted some opinions on this...

This is probably very dependent on where you rotated and what the actual training of the physician and the community they work in. Some private community hospitals are like this. And in truth, finding the private MD, when they have it is a good thing.

While one of the great things about EM is the undifferentiated patient, it is always better for the patient if you know something of thier history. This is where privates come in. It is possible that because of your lack of training, that it only appeared that the EMP was just 'getting' someonelses plan. There are numerous times that I will explain why the privates plan needs to be altered, confirmed, deleted or added to.

Often, because of where I work, I have no privates. We only consult our off services for things that we can't do. Ie: surgeons to remove an appy, Cards to take someone to the cath lab, ortho to take someone to the OR for a fractured hip.

EMP's practice emergency medicine. It probably just seems different to you than 'normal' medicine because it is. Our job is not to manage patients on a long term basis. It is to diagnose and treat acute problems, determine and deal with life threatening illnessess and determine if a patient can go home for further management by thier private doctor or if they need to be admitted. The entire framework for EM is entirely different from the rest of medicine. It is often why it looks so different and alien to those just starting thier path in medicine.

There are multiple threads on this in the EM forum, you may also want to try searching there to get a variety of opinions.

 

[beyond all hope]

SDN folks,

I'm a relatively new graduate (1 year out) and a core faculty member in an Emergency Medicine residency. I also help run the medical student rotation at my program, so I mentor students and residents on a regular basis regarding the rotation, the match, residency and post-residency life.

The basics:

1. What do you enjoy most about your specialty?
No surprises here. I like the acuity and the breadth of pathology. Treating all ages from newborn to the elderly. I thrive on the fast-paced environment, working in a team of crazy cool people (students, residents, nurses, techs, other attendings, etc). I like getting to the heart of the matter quickly.

I would not be happy in a surgical specialty which requires patience in order to get good results, nor in a medical specialty where I was primarily handing out pills, or in pediatrics where you treat mostly social issues and parents.

I like a work schedule that is chosen in advance, and that I only work 2-3 shifts a week. I like the fact that I don't own a pager.


2. Is there anything you dislike about your specialty?

Lack of continuity of care. Abusive, apathetic patients. Not being an 'expert' in any one field and always having to consult doctors who know more about the subject than I do (hopefully).

3. How many years of post-graduate training does your specialty require?

Three to four. Most EM docs don't do fellowships, even in academics, but they are available.

4. What is a typical schedule like for your specialty? Are the hours/shifts flexible?

Most community docs work 30-40 hours per week. Most academic docs work less clinical hours (usually 24-36) but have nonclinical responsibilities such as research, administration, teaching and mentoring which can take up a lot of time. The more involved in academics or administration, the less clinical hours one is likely to work. Usually 8-12 hour shifts, and most of full-time docs work 3-6 overnights/month.

5. Where do you see your specialty going in five years?

The demand for board certified EM docs continues to grow. Many project it will level off in five or ten years. Still very easy to get a job just about anywhere in the country.

 

[beyond all hope]

Many ask this question.

Academics is a broad category that means you are somehow involved in the teaching/research of Emergency Medicine. Community medicine means you simply see patients and practice EM.

Many docs are involved in both. There are many community hospitals that rotate EM residents or IM/Surgery/Peds residents, and so those attendings are involved in teaching +/- research. There are a few academic centers which are heavily geared towards patient care/satisfaction and so the attendings do very little academics.

Then again, there are many docs who only practice community medicine, and there are a select few academic docs who no longer practice medicine but simply do teaching/administration/research.

Community medicine tends to pay more money - no surprise.

Some people say that it's harder to break into academics than do community medicine, which is basically true. There are far more community EDs than academic centers so it may just be a matter of numbers. However, the job market is still quite open in both academics and community medicine.

Most people think they have to decide what kind of medicine they'd like to practice, but that's just not true. Many docs jump back and forth between academics and community, or practice both at the same time.

To advance in academics, however, you have to continue to publish on a regular basis and become an expert in your chosen field.

 

[beyond all hope]

This has been done to death, but just to review.

1. Board scores
2. LORs
3. Clinical rotation grades, especially EM
4. Interview
5. Performance in audition rotation
6. Others such as med school prestige, mutual friends/contacts, etc

Not necessarily in that order. First you sign up for the match and send out applications. Then, if you have good enough grades/boards to get an interview, you're invited for an interview. At the interview, the interviewers decide if they like you, would enjoy working with you, and think you'll make a good EM doctor. You'll be ranked by the program based on a composite of the factors above.

Then you make your rank list. If your first choice ranks you high enough to get a spot, you get your first choice. If not, you go to the next. When your highest choice actually ranks you high enough to accept you, you've been accepted. Congratulations!

 

[beyond all hope]

Not too hard. The job market in EM is wide open, and EM trained physicians are a hot commodity. Most people are more interested in location than type of job, so they look at EDs in the area they want to work and pick their top choices. Options:

1. Go through contacts. You know/your friend knows chairperson at Perfect Hospital where you want to work. You go through said channels to get an interview.

2. Cold call/email chairperson of Perfect Hospital with your resume. This is perfectly acceptable in the EM world as long as it's done in a professional manner.

3. Go through a recruiter. Also perfectly acceptable. Just remember that most of the good jobs never go to a recruiter, so you're often looking at the less-desirable places, frequently ones with a high turnover (although not always.)

How to choose a good job is a topic in of itself. AAEM, ACEP and other organizations print guidelines of what to look for, or you can ask seasoned professionals in your field.

 

[beyond all hope]

Simple stuff.

Be professional.
Be prompt.
Be enthusiastic.
Be knowledgeable (as much as possible. That's what you're here for)
Care about your patients.
Follow up on the details.
VERY important. You should always know exactly the status of your patient/patients (lab results, waiting for what test, general state of being). The more in control you are of the details, the more your supervisor will feel comfortable giving your more responsibility

Enjoy yourself (if you're not, either you're in a bad environment or EM is not the choice for you)

Specific to EM:
Don't take too long for your H&P. Fifteen minutes is a good rule for a history and physical in the ED. If you disappear with a patient for an hour, that leaves the resident/attending out of the loop and is potentially dangerous for a sick patient. You won't be able to get all of the details. Try to get the important points.

Clothing choices are usually more relaxed. Scrubs, scrub tops with cargo bottoms and sneakers are usually acceptable. Most EDs do not expect a tie and nice clothes, and many of us discourage it (gets dirty). White coats are optional in some EDs. Ask before you start the rotation.
Never: jeans, t-shirts, any torn clothing, low-cut blouses, open-toed shoes, skirts (unless very tasteful with coat).

Reading while in the ED. I recommend it. Take 10-15 minutes after every patient to read up on the disease process, treatments, etc. You will learn much more quickly and retain more that way. Be warned: some people see a med student reading and they think it means slacking.

Do procedures. IVs, Foleys, NGTs, ABGs, LPs, fx reduction, etc. Intubate or do central lines if you can, but don't expect it.

 

[WorkinEM]

hi graylin
its so nice to find a forum like this, which has been really useful so far
i am a 4th year medical student who will be applying for EM residencies mostly in new york city and boston. i am looking to see how competitive of a candidate i am, and if you had any opinions on certain programs in the northeast? i didnt decide until recently that i want to do EM and therefore havent been involved in any EM interest groups. will this hurt my chances? my numbers are- 233 on step 1, honors in medicine, surgery and ob-gyn, and high pass in peds and psych. i havent received my grade yet for the EM rotation i just completed. so far i have one LOR nailed down that i think will be very good. i did some clinical research a couple of years ago and have random experience volunteering, tutoring, etc.

do programs look at 4th year grades as well? right now i am in the ICU and then doing another EM rotation.

i am really curious as to how i will do in the match. the dean at my school says i will do really well (she is not in EM). i am just starting to feel some anxiety as to the whole process and would like to feel a little more confident that i will match somewhere!! i would appreciate any feedback, i hope this was the appropriate place to post such a question!
sincerely
kat

It's really tough to answer these questions about what your chances in the match might be. Match is more than just numbers. It's also about how you interview and which programs you choose to rank highly. The things programs look at most highly change from program to program and year to year. I suggest doing the best you can and when you get anxious about matching research more programs that you might be willing to go to. The majority of people who don't match (which is really a minority) didn't rank enough programs. For you, you can expand your chances by looking at programs in upstate NY, Philly, Boston, Jersey and PA.

 

[WorkinEM]

I am definated interested in both fields but of course - trauma is a surgical fellowship that requires all the stuff that goes along with a surgical residency and EM is not as intensive of a residency from my observation. however, EM seems to more dealing with minor accidents and acute stomach aches while trauma get the big boy cases. this is all from what i've observed at a busy urban level 1 trauma center but would like some input from those who have experience in either field.

Just so you know your post comes off a little bit insulting toward EM. I'm sure you don't intend it but it sounds like you are really interested in trauma surg but are looking at EM as a possibility because you think it might be an easier course.

EM is a totally seperate field from trauma surgery. Trauma surgeons take care of trauma patients and usually go general surgery as well. EPs take care of everybody. When you say "big boy cases" I assume you mean the surgical trauma cases. Yes, the trauma surgeons take those to the OR. In most community centers those patients are stabilized by the EP before going to surgery. EPs deal with the MIs, cardiac arrests, resp failure, sepsis, gyn, peds, etc. etc. etc.

If you want to treat trauma patients exclusively and if you will only feel rewarded if you are the one taking the "big boy cases" to the OR you should forget about EM and go forward in surgery. EM will not do it for you.

 

[beyond all hope]

There was a concern early on in the specialty that a lot of docs got burned out by EM. Recent studies have shown the burnout rate for EM is similar to other specialties. Remember early in the specialty there were mostly non-EM trained docs in EDs, so they didn't choose the life of EM and weren't necessarily prepared for it.

Now that the specialty is maturing you see a lot of docs in their 50s, 60s and 70s very happy and comfortable in EM. Many do reduced night shifts or none at all.

I'm still young so I can't say from experience, but the older docs in EM are some of the strongest. Can't beat an EM trained doc with 15-20 years of experience under his/her belt.

 

[Graylin]

I apologize for not being around. I am on vacation and will return soon.

 

[WorkinEM]

I have always been interested in becoming a EMP. B/c of low academics in undergrad I'm trying to find other ways to get more exposure in order to increase my chances into medical school. I am thinking of taking an EMT-B class but was not sure if this would help or hurt? What is your take?

This kind of stuff helps a little but not as much as grades. If you're looking to see if you really like medicine and want to go to med school or not then that type of experience can be helpful. If you're comitted to med school and you're looking for a resume builder you'd be better off putting the extra time into studying and doing better on grades and the MCAT.

 

[WorkinEM]

Hi, Graylin.

I am a PGY-III at ... Residency Program and I'm interested in pursuing a second residency in Emergency Medicine after I graduate this year. I am hoping you can give me some advice on how to go about doing this.

I chose ... because it offers a rural emergency medicine/acute care specialty track designed to prepare residents for rural EM practice (as many of the ED's in ... are staffed by FP's). Over the past 2 years, however, I have come to realize that my training here, albeit excellent in primary care, will not provide the type of training I feel I need to become a competent ED physician. I feel strongly enough about this that I am willing to repeat a second residency in order to become board certified in EM. My ultimate goal is to serve as a rural ED physician, EMS director and EMS educator.

Are there any EM programs, particularly in the more rural states, that are receptive to residents seeking a second residency? If so, do all require that I go through the Match? I'd like to avoid this ordeal since I fear that my application will be filtered out due to my IMG status (even though I am a US citizen, ECFMG certified and awaiting a medical license) and a less-that-stellar Step 1 score (Step 2 and 3 were very good and I have scored the highest in my class on yearly in-service exams).

One last question....how much of my prior EMS experience and current emergency medicine and EMS-related teaching certifications should I mention on my CV? Prior to med school, I was a paramedic and EMS instructor. I have maintained my NREMTP certification and I am an active ACLS, CPR, PALS, NRP and ATLS instructor. Despite my age (a very young 45...) and an extensive EMS background, I am very "trainable", otherwise I would not have done as well as I have in my current residency.

As I stated above, I am willing to start over again just to make sure that I get the proper emergency medicine training. I truly believe that my current FP training coupled with a strong EM residency program will make me an outstanding rural emergency medicine physician. I'd be greatly appreciative if you could give me any advice on how to achieve this goal.

I didn't intend for this to be so lengthy...so thanks in advance.

(personal identifiers removed by WorkinEM)
There is no way to become board certified through ABEM with an FM residency. If that's what you want you will need to retrain.

That said I think you would be a viable candidate for an EM residency due to your CV. I would list everything you have done with EMS. I don't see your Step 1 score as a problem if your other steps were ok and your residency was without problems.

As for rural EM programs the only one that leaps to mind is the program at Scott and White in Temple TX. You can look around for a program in a bigger town that has opportunities in smaller settings. Check out some webpages for individual programs.

Given that you will be a full fledged FM doc during your EM residency you may want to look into an EM program that will allow you to moonlight (urget care, nursing home, etc.) as you could significantly imporve your financial picture.

Good luck.

 

[Graylin]

Hi Graylin. First of all, thanks a million for all your help.

I am an IMG trying my best to enter the very competitive and IMG-unfriendly world of EM. My question is, how come EM is one of the most (if not THE most) IMG-unfriendly specialty? There are many other more competitive specialties that have a larger proportion of IMGs.

Again, thank you very much for taking the time to read and answer our questions.

EM is not IMG unfriendly. I have no idea what this is based on or why you seem to think it is the most unfriendly. It is a competitive specialty, and one that doesn't have a vast number of spots open (as opposed to FP, IM, Gen surgery). Some programs are not IMG friendly at all. Some are very friendly. Just like almost any other specialty.

 

[Graylin]

How much do your grades from the first and second years count for EM? I heard they are lower on the list for many residencies and didn't know if this was the same. Thanks!

As you know, there are no universal answers to this questions. Grades are important. In some programs, they are going to be very important. In some, no so much. For most, it is one of many things that are looked at, to gain an overall picture of the applicant. Thus, good grades will never hurt you, bad grades might, and in some cases, definately will.

 

[Graylin]

I am apply to EM residencies this cycle. Everyone says to apply "broadly" and to interview at a range of programs, not just competitive ones. My question is how do you know how competitive a program is? Most people say there are no bad EM residencies and to just go with the ones that fit you most but how can you make sure you have some backup programs as well as some reach programs on your interview list?

The advice to apply broadly is good advice, but definately difficult to sort out. You first should probably decide on some general location issues. There are a couple of places you can look to find out the competitiveness of programs: the EM forum is a great spot. Just do a search. The next, and most valuable, will be to speak with your EM advisor. Unfortunately, there are way to many programs to just start listing them off. Try and figure out what part/s of the country you are interested in, and also what general type of program you are interested in. It will make it alot easier to start figuring out where to apply.

You can also check out websites like www.scutwork.com. it won't tell you so much about competitiveness but it will give you some feedback on what the programs are like.

 

[Graylin]

I am confused about the SLOR. Is it required by some or all programs? Or is what gets sent through ERAS enough?

The SLOR is the Standardized Letter of Recommendation. It is the preferred format for EM LOR's. It is not mandatory. But the vast majority of EM faculty who will write you a LOR will use this form. Your other LOR's will be in the traditional format.

My .02 on why the SLOR is preferred? It is easy to fill out, easy to read, gives the high yield information and has room for free comments.

 

[Graylin]

Our local level I Trauma Center (Wake Forest University) is a large academic hospital. Can one work as an EM doc in a place like this without being an "academic physician" or are the private practice EM guys only relegated to smaller community hospitals and urgent care facilities that may be less busy or not see as much larger amts of trauma?

This is a complicated question. First, you seem to operating under the misconception that all non-academic ED's are small, nonurgent ED's. The acuity of what you see is not based on your level status. In many smaller ED's, you will see trauma (stabilize and fly out) because you are the only person in the game at that point. Level one status has to do with the hospital staffing etc in house. It only 'diverts' when there are multiple hospitals in the area. Most EMP's do not work in urgent care facilities, unless it is by choice.

Many 'non-level 1' ED's are incredibly busy and see many many sick patients (trauma only constitutes a small percentage of 'sick' patients in and ED)

Regarding the 'non-academics' working in 'academic' ED's, this is incredibly subjective. What do you mean by non-academic? Do you mean not teaching residents? doing research? Its a vague description.

Many people aren't 'academic' and work in academic centers.

 

[WorkinEM]

Originally Posted by studyinghard
Our local level I Trauma Center (Wake Forest University) is a large academic hospital. Can one work as an EM doc in a place like this without being an "academic physician" or are the private practice EM guys only relegated to smaller community hospitals and urgent care facilities that may be less busy or not see as much larger amts of trauma?


Where I did residency (UC Davis) there was a "clinical track" for attendings who wanted to concentrate on clinical work and teaching and avoid doing research. They did have to teach residents and med students. The also had to have an area of expertise that they would lecture on about twice per year at the academic round mornings. For example one guy was big on regional anesthesia, others on ultrasound, etc. They worked more hours than the academic docs, usually ~2 shifts a month. I don't know how widespread this type of arrangement is but they are out there.

 

[Graylin]

I am interested in EM. How much trauma do you deal with? also, what sort of opportunities are there for procedures?

how competitive is EM?

The trauma load depends on the institution, the practice setting, etc. There is no definative answer to this question. You can go somewhere with high volumes or trauma or very low. It is only one aspect of EM. For procedures, scroll through the forum here. This has been answered.


Regarding competitive, EM is fairly competitive. There is a great thread in the EM forum that goes over this and gives numbers.

 

[WorkinEM]

Hello and thank you so much for taking the time to help all of us out!!
My question is one you may have heard before but I hope you can lead me in the right direction. I have been interested in EM from the time I started considering medical school and I really don't see myself doing anything else. I went back to school late in life and I am now 37 and have just finished MSII. Now I am not sure if I killed any chance at getting an EM residency but 1. I went to AUC because I didn't want to wait for the year of interviewing etc. 2. I had to leave AUC mid semester because my 8 y.o daughter was a victim of a sexual assult and I needed to be home with her until things got straightened out. During this ordeal AUC was unwilling/unable to work with me in regard to a withdraw from the semester because we were 5 weeks in at this point so I had to take F's in my courses and take a leave of absence to deal with things at home. 3. Because of the treatment I received at AUC I decided to leave and transfer to SMU where the school is much more family friendly and willing to work with students to achieve their dream not just collect the tuition. 4. After all this I decided I needed to take a semester after MSII to review the material I had at AUC before taking the Step 1 exam which I am currently waiting for the results of. So by taking the extra time and switching schools did I just make it impossible to get into EM anywhere?! I am not interested in top of the line programs and could be happy almost anywhere but would prefer Michigan if I could.
The other question I have is I like to work nights and I hate the day shifts any chance I can find an all 3rd shift position after if I can get a residency to start with?

I know a lot of info for 2 questions but I am really feeling hopeless and I hope you have some enlightening information for me.

Thanks again for you time

I don't think you're facing an impossible task of getting an EM residency but you will need to bounce back from these issues with very solid grades and boards. Once you're applying you will need to talk to some advisors about how to do damage control. Options are discussing in your personal statement, asking your LOR writers to address the issues specifically and so on.

Out of residency you will not have any trouble at all finding a job where you can work nights exclusively. In fact you will be sought after and paid better for being willing to work all nights.

 

[Graylin]

I am currently filling out my ERAS and am having a hard time with the "none" under "Medical School Honors/Awards". The SAEM guide says to "try not to let any of the fields say 'none'" Even if I am fortunate enough to get AOA (unlikely) I would not know until after the application is submitted.

I was wondering if I could put down something like my MD-PhD training grant as an award? Or what else would count as a med school honor/award besides AOA?

I think this type of advice is more anxiety promoting than anything else. If you can't fill in a blank, don't stretch to make something fit. I think that there is a place for grants. If there is not a seperate area, then you could probably put it there. Awards are awards. I think my school had things like 'most humanitarian' and other things like that.