Transitioning from residency at a large academic center to a suburban community ED: what do you wish you would have learned?

[Charmander94]

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I am finishing my residency at a large academic medical center on the East Coast and will be starting a community EM job in the South, which is entirely RVU-based. Like many academic centers, my residency has certain blind spots: I’ve had constant access to consulting services, dealt with significant boarding issues that limit patients seen per hour, and received little to no formal training in billing and coding.

I have a month of elective time this spring, I’m seeking advice on how best to prepare for this transition. What skills or experiences do you wish you would have gained before entering the community ED setting?

Some areas I’m considering include:
• Additional training in orthopedics or urgent care
• Focused education on billing and coding
• Medical malpractice case reviews
• Any other practical skills that are particularly useful in a community setting

I would love to hear any thoughts on what would have been most helpful for you before making a similar transition. Posted on reddit but hoping for some insights here.

 

[EctopicFetus]

How to work with MLPs.. finding ways to be efficient.

New grads are always and almost by rule slow.. thats ok.. some of the academic residencies dont focus at all on patient satisfaction (may or may not be a big deal at your job), very few feel any pressure to move the meat. Billing and coding is important if you are going to an RVU based system. You can focus your documentation now to do better in that aspect..

If you dont have experience with low acuity stuff get some. When i was a resident i worked with an attending who never saw low acuity patients in her residency. She was incapable of discharging a patient without ordering something no matter how dumb..

 

[hopeful22213]

Your suggestions are all reasonable to brush up on, and I'd second what EF said above.

I'd also add: personal finance. Make sure you understand the basics which will help prevent you making mistakes later. Understand 401k/403b, HSAs, brokerage accounts, backdoor roths, and avoiding whole life insurance (aka universal life, permanent life, universal indexed life) like the plague.

 

[Arcan57]

Your consultants will usually be attendings which is a different game from dealing with consultant residents.

 

[BoardingDoc]

Additional training in orthopedics or urgent care

There is one east coast residency where I moonlighted as an attending during COVID. I was explicitly told that any fracture or dislocation (including shoulders) should have orthopedics consulted to come reduce it. They confirmed that the EM residents didn't do that in the ER there. WTF.

If you don't feel comfortable reducing a fracture or a joint, I would try to get some exposure doing so before you head to a community shop, as calling Ortho to do any of that is not a realistic expectation in most smaller places.

 

[EctopicFetus]

There is one east coast residency where I moonlighted as an attending during COVID. I was explicitly told that any fracture or dislocation (including shoulders) should have orthopedics consulted to come reduce it. They confirmed that the EM residents didn't do that in the ER there. WTF.

If you don't feel comfortable reducing a fracture or a joint, I would try to get some exposure doing so before you head to a community shop, as calling Ortho to do any of that is not a realistic expectation in most smaller places.

lol.. our ortho guys want to do nothing. Literally never seen one come in at one of my hospitals (been there 10 years). If we in the ED cant reduce something it is right to the OR..

1 time I had a patient with a Colles fx, i cant remember why i called them (different hospital) and they came down and saw the patient. I never call ortho but something must have been Different with that case.

I think many new grads have no idea how to manage MLPs. Many have been at the site 15 years and are much older than the new grads. The challenge imo is they are managed differently at different places. I would focus on this as this is not something that is taught in residency and there is tremendous variability which is site specific.

 

[Arcan57]

Oh, damn. Forgot about the thing that threw me the most out in the community early on (besides the MLP thing). Referral patterns. Most community hospitals exist with a tightly woven group of docs that have specific referral patterns. Messing with these referral patterns is a fantastic way to piss off medical staff without doing anything medically wrong. Remember for a lot of docs, these patients are not just their private patients from a sense of caring about their well being, but in a very real way are how the docs keep the lights of their clinic on. Mrs. Jones with her stable CHF is good for a minimum of 4 office visits a year +/- an in office echo or stress. Admitting her to the hospitalist that uses Broadstreet Heart as their consultants instead of Wide Road Cardiology means that follow-up money has effectively been transferred from one group to another. And as you may have noticed, docs get really touchy when their income is threatened.

 

[Charmander94]

Your suggestions are all reasonable to brush up on, and I'd second what EF said above.

I'd also add: personal finance. Make sure you understand the basics which will help prevent you making mistakes later. Understand 401k/403b, HSAs, brokerage accounts, backdoor roths, and avoiding whole life insurance (aka universal life, permanent life, universal indexed life) like the plague.

lol.. our ortho guys want to do nothing. Literally never seen one come in at one of my hospitals (been there 10 years). If we in the ED cant reduce something it is right to the OR..

1 time I had a patient with a Colles fx, i cant remember why i called them (different hospital) and they came down and saw the patient. I never call ortho but something must have been Different with that case.

I think many new grads have no idea how to manage MLPs. Many have been at the site 15 years and are much older than the new grads. The challenge imo is they are managed differently at different places. I would focus on this as this is not something that is taught in residency and there is tremendous variability which is site specific.

Thankfully I am relatively well-versed in personal finance for a resident; planning to create an S corp and will backdoor and mega backdoor Roth.

MLPs staff with senior residents here so thankfully I have that experience as part of my residency (and I understand navigating the dynamic between a new doc and a PA who’s practiced in the ED for 15 years).

It’s looking like ortho may be one of the biggest weak points then. Attendings heavily encourage us to consult ortho for simple fractures so we can keep seeing other patients.

Any advice in terms of how to most effectively brush up on ortho skills in a month of elective? Ortho urgent cares? ED near ski destination? Any books or guides you recommend?

Thank you all.

 

[Arcan57]

Thankfully I am relatively well-versed in personal finance for a resident; planning to create an S corp and will backdoor and mega backdoor Roth.

MLPs staff with senior residents here so thankfully I have that experience as part of my residency (and I understand navigating the dynamic between a new doc and a PA who’s practiced in the ED for 15 years).

It’s looking like ortho may be one of the biggest weak points then. Attendings heavily encourage us to consult ortho for simple fractures so we can keep seeing other patients.

Any advice in terms of how to most effectively brush up on ortho skills in a month of elective? Ortho urgent cares? ED near ski destination? Any books or guides you recommend?

Thank you all.

The secret to reducing joints is sedation. There are a million cool ways to put back in shoulders and hip and elbows, but propofol makes them all way easier. If you can't get it, make them sleepier. Also, reducing a tri-mal is super easy. Holding the reduction until the splint dries is significantly harder and in most cases should be an attending level procedure.

 

[EctopicFetus]

Thankfully I am relatively well-versed in personal finance for a resident; planning to create an S corp and will backdoor and mega backdoor Roth.

MLPs staff with senior residents here so thankfully I have that experience as part of my residency (and I understand navigating the dynamic between a new doc and a PA who’s practiced in the ED for 15 years).

It’s looking like ortho may be one of the biggest weak points then. Attendings heavily encourage us to consult ortho for simple fractures so we can keep seeing other patients.

Any advice in terms of how to most effectively brush up on ortho skills in a month of elective? Ortho urgent cares? ED near ski destination? Any books or guides you recommend?

Thank you all.

Much of this depends on experience. I dont know of an easy way to do this. I would consider doing an ortho elective to practice splinting. depending on where you work you may need to do these. I cant think of a place where y ou will do a ton of reductions. Doubt Ortho urgent cares do many. As mentioned you need to sedate people to do real reductions like hips. Shoulders are overrated.

Re finance may main advice would be to listen to others you work with. While you may know a lot there are really smart docs doing it now. DB plans may be a wise option. Depending on your personal situation having your spouse do REPS is a major way to get rich quick.. but you know rules and desires matter.

My main point is learning to manage the MLPs.. sounds like you guys do that in your residency which is great. The culture of where you work will matter. The more dysfunctional your site is the more power the MLPs will have and the more issues you may end up having. Just an old dudes 2 cents. I refuse to work anywhere where the MLPs have that much power but i have witnessed it.

 

[bougiecric]

I will never not be annoyed at how backward orthopedic training in emergency medicine is.

Residency: ortho does all the reductions
Community: ortho does none of the reductions

So dumb.

 

[JacobMcCandles]

I will never not be annoyed at how backward orthopedic training in emergency medicine is.

Residency: ortho does all the reductions
Community: ortho does none of the reductions

So dumb.

That’s pretty consistent with most residencies who consult for everything. They’re just doing their residents a disservice.

 

[WhatJobDoIPick]

Thankfully I am relatively well-versed in personal finance for a resident; planning to create an S corp and will backdoor and mega backdoor Roth.

MLPs staff with senior residents here so thankfully I have that experience as part of my residency (and I understand navigating the dynamic between a new doc and a PA who’s practiced in the ED for 15 years).

It’s looking like ortho may be one of the biggest weak points then. Attendings heavily encourage us to consult ortho for simple fractures so we can keep seeing other patients.

Any advice in terms of how to most effectively brush up on ortho skills in a month of elective? Ortho urgent cares? ED near ski destination? Any books or guides you recommend?

Thank you all.

Your first mistake is making an S corp. Very likely you're better served making an LLC and opting to tax it like an S corp.

 

[WhatJobDoIPick]

My two cents:

1) you're probably in for a rude awakening going to RVU only shop right out of training. This is not a bad thing necessarily

2) become intimately familiar with the 2023 billing and coding changes. One of the biggest drivers in the MDM is independent interpretation of studies. You only need to do one. If it's an EKG you need 3 date points (rate/rhythm/ischemia), if an X-ray or CT you only need one ("no acute infiltrate")

3) Always be dispositioning. Constantly run list and see who can be admitted or discharged.

4) bill critical care aggressively. Blood transfusions, IV electrolyte repletions, anaphylaxis, any IV rate or blood pressure agent...all get critical care billing

5) sitting down helps w patient satisfaction. Patients love to be told they're dehydrated and stressed. Give IV fluids, bentyl, flonase, Albuterol, etc for all the BS complaints. Nod and smile a lot. Say "that's so hard."

6) some patients can't be pleased no matter what. Identify those as quickly as possible and do the minimum you need to do to get them out. Don't spend any extra time with them

7) Ortho is whatever. Push, pull, splint, refer. Shoulders and hips are easy enough and you should be proficient at those. My radius fracture reductions aren't the prettiest, whatever.

8) you're gonna be faced w situations where in order to to the right thing for the patient, you have to piss people off (nursing, patient, consultant, hospitalist). Those are the most difficult situations we face.

9) protect yourself and staff. Sedate patients who need it. Kick them out if they need it.

10) notes are done by shift and and aim to escape within 30 minutes of shift end time. This will be difficult in the beginning.

11) figure out what your boss cares about and focus on that. Try not to make waves. Make their life easier.

 

[throway134]

My two cents:

1) you're probably in for a rude awakening going to RVU only shop right out of training. This is not a bad thing necessarily

2) become intimately familiar with the 2023 billing and coding changes. One of the biggest drivers in the MDM is independent interpretation of studies. You only need to do one. If it's an EKG you need 3 date points (rate/rhythm/ischemia), if an X-ray or CT you only need one ("no acute infiltrate")

3) Always be dispositioning. Constantly run list and see who can be admitted or discharged.

4) bill critical care aggressively. Blood transfusions, IV electrolyte repletions, anaphylaxis, any IV rate or blood pressure agent...all get critical care billing

5) sitting down helps w patient satisfaction. Patients love to be told they're dehydrated and stressed. Give IV fluids, bentyl, flonase, Albuterol, etc for all the BS complaints. Nod and smile a lot. Say "that's so hard."

6) some patients can't be pleased no matter what. Identify those as quickly as possible and do the minimum you need to do to get them out. Don't spend any extra time with them

7) Ortho is whatever. Push, pull, splint, refer. Shoulders and hips are easy enough and you should be proficient at those. My radius fracture reductions aren't the prettiest, whatever.

8) you're gonna be faced w situations where in order to to the right thing for the patient, you have to piss people off (nursing, patient, consultant, hospitalist). Those are the most difficult situations we face.

9) protect yourself and staff. Sedate patients who need it. Kick them out if they need it.

10) notes are done by shift and and aim to escape within 30 minutes of shift end time. This will be difficult in the beginning.

11) figure out what your boss cares about and focus on that. Try not to make waves. Make their life easier.

My personal take on Ortho: if you aren’t comfortable with it, call them early and often to look at your post-reduction film. Can also use an older ed doc if you trust them, but be cautious with this.

Yeah, you might piss off the Ortho doc, and try not to do this at 4am, but if it’s 3p and you’re wondering if that’s an adequate reduction call them or their mlp who worked with them for 20 years to ask.

People have a lot of ego and don’t do this when they’re new grads, then get 5 complaints to their med director about inadequate reductions or get blamed for absurd complications.

Also, your threshold to send anything to a hand dedicated person in follow up (not transfer) should be close to zero, and document the crap out of telling people that delayed follow up with hand can lead to disability and missed/delayed dx. I didn’t practice long in em and even in my short interval watched multiple people get Qi’s or get sued for missed hand path and incomplete tefuctions

If in doubt, call the person who will judge you after the fact. It reduces Monday morning qb. Can be an 8 second phone call, only make them come in if they’re royaling fing up (missed nec fasc or whatever).

 

[EctopicFetus]

My two cents:

1) you're probably in for a rude awakening going to RVU only shop right out of training. This is not a bad thing necessarily

2) become intimately familiar with the 2023 billing and coding changes. One of the biggest drivers in the MDM is independent interpretation of studies. You only need to do one. If it's an EKG you need 3 date points (rate/rhythm/ischemia), if an X-ray or CT you only need one ("no acute infiltrate")

3) Always be dispositioning. Constantly run list and see who can be admitted or discharged.

4) bill critical care aggressively. Blood transfusions, IV electrolyte repletions, anaphylaxis, any IV rate or blood pressure agent...all get critical care billing

5) sitting down helps w patient satisfaction. Patients love to be told they're dehydrated and stressed. Give IV fluids, bentyl, flonase, Albuterol, etc for all the BS complaints. Nod and smile a lot. Say "that's so hard."

6) some patients can't be pleased no matter what. Identify those as quickly as possible and do the minimum you need to do to get them out. Don't spend any extra time with them

7) Ortho is whatever. Push, pull, splint, refer. Shoulders and hips are easy enough and you should be proficient at those. My radius fracture reductions aren't the prettiest, whatever.

8) you're gonna be faced w situations where in order to to the right thing for the patient, you have to piss people off (nursing, patient, consultant, hospitalist). Those are the most difficult situations we face.

9) protect yourself and staff. Sedate patients who need it. Kick them out if they need it.

10) notes are done by shift and and aim to escape within 30 minutes of shift end time. This will be difficult in the beginning.

11) figure out what your boss cares about and focus on that. Try not to make waves. Make their life easier.

#9.. All day... #9.. dont let some idiots behavior make a mess of your ED.. FAFO.. misbehave.. ill manage it.. zzzzzzzzz

 

[Rendar5]

The secret to reducing joints is sedation. There are a million cool ways to put back in shoulders and hip and elbows, but propofol makes them all way easier. If you can't get it, make them sleepier. Also, reducing a tri-mal is super easy. Holding the reduction until the splint dries is significantly harder and in most cases should be an attending level procedure.

Trimal splinting is as easy as the reduction if you know the trick. Post reduction, just grab the big toe and hold it up in the air a a few inches above the bed. Don’t touch anything else. Not the foot, not the ankle, not the leg. Everything falls into position. And if you’re in a time crunch just show the medic how to do it.

To the OP:
I was in a program where ortho did every reduction but shoulders. (Don’t ask me how we wrestled that procedure from them). I got to do 1 trimal the entire residency because the attending couldn’t feel a pulse (wink, wink) and couldn’t wait for ortho to show up. I watched ortho do their reductions and then did a couple community fast track rotations electively to learn the stuff on my own. you’ll figure out which shoulder technique works for you, hip has 2 techniques, and everything else is essentially 1 technique.

Sedate hips, and anterior shoulders (unless you master some of the awake techniques), hematoma blocks for fractures unless theyre peds or the block doesn’t take, and analgesics for dislocations of elbows, fingers, patellas since those slide in easily.

As for the rare ones like perilunates or oosterior shoulders just YouTube or google them. They’re rare enough where you won’t get stupid techniques posted. And if you don’t get them, ortho will understand.

If you’re nervous, have your partners do a couple with you when you’re first out. They’ll understand. I got comfortable with ortho within a few months out in the community.

 

[Rendar5]

If you ever want to talk medmal I’d be happy to chat. I love that ****. ACEP has a great paper on 10 things to do as an attending to mitigate malpractice if you look for it. Just practice somewhat conservatively, stick to established standards. if the patient looks great to you or you think they’re just malingering or overly anxious or a hypochondriac, just treat them based on how they write out objectively in your note. Give all those characters the benefit of the doubt. Yes Ms. Anxiety, I will check the ddimer. No problem Mr. Crazy I’ll scan your brain to look for worms. Yes second bounceback for parethesias in your toe, I will admit you for an MRI. Majority of cases you will be right from the get go. But you will be surprised by what you find on a decent minority of cases.

And ALWAYS be aware of bouncebacks and have a super low threshold to just admit them. Of the 30 or so cases I’ve reviewed in the last two years, at least 10-20% of them were bouncebacks.

 

[EctopicFetus]

The bounce back thing is real. Hopefully you learned that in residency.

 

[thegenius]

I am finishing my residency at a large academic medical center on the East Coast and will be starting a community EM job in the South, which is entirely RVU-based. Like many academic centers, my residency has certain blind spots: I’ve had constant access to consulting services, dealt with significant boarding issues that limit patients seen per hour, and received little to no formal training in billing and coding.

I have a month of elective time this spring, I’m seeking advice on how best to prepare for this transition. What skills or experiences do you wish you would have gained before entering the community ED setting?

Best way to prepare is to take a vacation, go to the pub, paint your house, have sex with your gf/wife, and about 2000 other things rather than what you think you should do.

Once you become an attending for 6 months or more, you will wish you did one of the things I suggested above.

 

[ERMudPhud]

Mostly what everyone else said. Especially what thegenius said. I would add that unless someone is dying you have time to look up a procedure and refresh your memory by reading or watching a video before you do it. No shame in that.
Don't make your consultants come in unless you need them to do something you truly can't do. I've usually found they are happy to talk me through something on the phone and look at images in the EMR or PACS afterwards if it means they don't have to come in. I did things in my first 6 months out that I never did in residency and continue to do new things every so often to this day. If I see a weird fracture or dislocation or if I fail on my first try I'll call ortho have them look at films and tell me what to do. A recent subtalar dislocation comes to mind. Try not to bother consultants between midnight and 6AM. If I call someone at 7AM I will sometimes even say, "They came in at 2am but I figured this could wait until 7am." That way when you really really do need to bother them they understand. Also, with the exception of a few bad apples attending to attending discussions are usually much more collegial. You work with them, they will work with you. Eventually you will have a good relationship with everyone, they will know and trust you, that makes everything easier.

Whoever is hiring you should have a presentation on billing and coding that they make you watch, unless they don't care about that stuff. They should also be giving you lots of billing and coding feedback over the first 6 months.

Oh yeah for wrist fractures finger traps are your friends. Hematoma block, dilaudid, hang them in traps, put two IV bags in 3 feet of stockinet and hang it over their elbow. Walk away for 20 minutes. Come back and straighten it out and splint. Don't even need a nurse or tech for help. easy as pie. Can similarly hang trimals by the big toe with a loop of paracord and splint with no help.

 

[Apollyon]

Oh yeah for wrist fractures finger traps are your friends. Hematoma block, dilaudid, hang them in traps, put two IV bags in 3 feet of stockinet and hang it over their elbow. Walk away for 20 minutes. Come back and straighten it out and splint. Don't even need a nurse or tech for help. easy as pie. Can similarly hang trimals by the big toe with a loop of paracord and splint with no help.

Out of your cargo pants? Because, IIRC, you're a (slightly) crunchy CO doc!

 

[ERMudPhud]

Out of your cargo pants? Because, IIRC, you're a (slightly) crunchy CO doc!

Out of my work bag. Right next to the leatherman. I'm known for wearing homemade batik scrubs at work. Because I'm crunchy I can also sew.

 

[Groove]

As long as you are graduating from a power house residency, you've got nothing to worry about.

 

[Rendar5]

What you need to know about documentation for billing purposes:

2023 Guidelines - ERNotes

2023 Documentation Starting January 1st, 2023 the CPT changes for E/M documentation in the ER take effect. This is a massive change in how we as providers document and adequately reflect the care we provide. Prior to this, we were taught to use the antiquated 1995/97 guidelines using the...

ernotes.net

you may want to also take a second to read up on how laceration repair coding works so you don’t short change yourself on those procedures.