UW Seattle EM residency

[crewmaster1]

Wow, just got back from a Q & A session with the Medical Director from Harborview (Dr. William Bremner) and some other folks (UW med director, Assoc chair, etc) talking about the future of a residency at UW/Harborvivew (our trauma center). No EM people, because they weren't invited. I'm so pissed off I can barely type!!

For those of you who don't know the Seattle situation: The University Hosp. is staffed with boarded EM attendings that function like normal EM attendings. The level one trauma center/county hospital (Harborview) is staffed with internal medicine attendings. These attendings see all patients except true trauma codes, for which surgery attendings are called in to see the patient. Both medicine and surgery residents work in the ED, but no EM residents.

So what does the future hold: Basically, they want to get an EM residency started, likely to happen in the next 5 or so years, but the harborview ER will continue to be staffed with the medicine and surgery docs (in reality only internists and the occasional trauma attending for a true trauma code), but have some EM attendings to supervise the EM residents (RRC requires 4 EM attendings and it doesn't sound like they want a whole lot more than this). He feels that Harborview needs to have specialists and consultants on the front lines because the patients they see at HMC are much "too sick" for only EM docs to see (I tried to explain that I just interviewed all over the country at many level one trauma centers that see many more patients than HMC all staffed by EM---obviously too complicated for him to understand). His basic take is that the system is working now, so why should they change it other than to meet minimum RRC requirements for a residency.

I also found out that the 3 EM attendings they have working at Harborview now are not being allowed to practice to their full scope. The Med Director said they are currently not allowed to intubate any patients ("because the RRC only requires 30 intubation during an EM residency and anesthesia has much more experience with this"---yes those are his words, yes I wanted to knock his teeth out and then intubate him on the spot) . However, the good news is they are thinking about letting the EM docs intubate "simple" airways, but of course not trauma airways those are "too complicated."

These people are ****ing nuts! They have no idea what the standard of care is across the country. I can't wait to leave Seattle. And to think I had hopes of coming back here to be an attending. Maybe I'll write more later, just wanted to keep you SNDers updated.

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[somedude98317]

that's quite disappointing to hear....but i'm not all that surprised because these dinosaur's of Medicine and Surgery are really set in their ways.

On the interview trail for a Prelim medicine spot, I mentioned i was interested in doing a critical care fellowship after my EM residency and the person interviewing me (who is a dinosaur of Pulm/CC) laughed and said the only thing that Critcal Care docs and ER docs have in common are:

1) They work in shifts

2) They "see" sick patients....then went to say that ER docs literally only "see" the sick but haven't a clue when it comes to properly taking care of them.

its safe to say i will not be ranking that program...

 

[SolidGold]

It's all a result of people feeling threatened that others are going to take over their specialty. I spoke to an EM attending at UPenn who did a critical care fellowship after his residency. He now spends 75% of his time in the ED, and 25% in the SICU. That's a place that gets it.

 

[southerndoc]

That's Copass for you. What do you expect when you have a neurologist running an ED?

 

[Arctic Char]

it must be something starbucks puts in the coffee . . . i did grad school at UW and this is the same kind of dense thinking that occurred in our department. i was relieved to leave seattle.

 

[TerraMedicX]

WOW...I'm really glad I read this!! I had been looking at UW and Harborview for a while now, but after hearing this, I guess I should re-think things. I find it really strange that the ED would be so archaic, when the Medic 1 program there is so amazingly advanced (possibly THE best prehospital program in the world!). It sounds almost like they trust their paramedics more than they trust EM docs! 😱

Nate.

 

[met19]

Wow, just got back from a Q & A session with the Medical Director from Harborview (Dr. William Bremner) and some other folks (UW med director, Assoc chair, etc) talking about the future of a residency at UW/Harborvivew (our trauma center). No EM people, because they weren't invited. I'm so pissed off I can barely type!!

For those of you who don't know the Seattle situation: The University Hosp. is staffed with boarded EM attendings that function like normal EM attendings. The level one trauma center/county hospital (Harborview) is staffed with internal medicine attendings. These attendings see all patients except true trauma codes, for which surgery attendings are called in to see the patient. Both medicine and surgery residents work in the ED, but no EM residents.

So what does the future hold: Basically, they want to get an EM residency started, likely to happen in the next 5 or so years, but the harborview ER will continue to be staffed with the medicine and surgery docs (in reality only internists and the occasional trauma attending for a true trauma code), but have some EM attendings to supervise the EM residents (RRC requires 4 EM attendings and it doesn't sound like they want a whole lot more than this). He feels that Harborview needs to have specialists and consultants on the front lines because the patients they see at HMC are much "too sick" for only EM docs to see (I tried to explain that I just interviewed all over the country at many level one trauma centers that see many more patients than HMC all staffed by EM---obviously too complicated for him to understand). His basic take is that the system is working now, so why should they change it other than to meet minimum RRC requirements for a residency.

I also found out that the 3 EM attendings they have working at Harborview now are not being allowed to practice to their full scope. The Med Director said they are currently not allowed to intubate any patients ("because the RRC only requires 30 intubation during an EM residency and anesthesia has much more experience with this"---yes those are his words, yes I wanted to knock his teeth out and then intubate him on the spot) . However, the good news is they are thinking about letting the EM docs intubate "simple" airways, but of course not trauma airways those are "too complicated."

These people are ****ing nuts! They have no idea what the standard of care is across the country. I can't wait to leave Seattle. And to think I had hopes of coming back here to be an attending. Maybe I'll write more later, just wanted to keep you SNDers updated.

personally sounds like the most ass backwards system ever....

 

[Dr. Will]

You know, I always joked that Seattle is isolated up in the northwest. This info has given me every reason to believe I'm right! 😛

 

[southerndoc]

WOW...I'm really glad I read this!! I had been looking at UW and Harborview for a while now, but after hearing this, I guess I should re-think things. I find it really strange that the ED would be so archaic, when the Medic 1 program there is so amazingly advanced (possibly THE best prehospital program in the world!). It sounds almost like they trust their paramedics more than they trust EM docs! 😱

Nate.

Medic One was the best in the world when it was created. However, despite having the most trained paramedics in the country (3600 hours), Medic One still relies on verbal orders for most medications. Paramedics only have standing orders for cardiac arrest algorithms and IV's. Even nitroglycerin to a chest pain patient requires discussion with medical control. (Unless things have changed in two years.)

Copass maintains tight control of the paramedics. He QA's every single patient care report generated by a paramedic, and it's not uncommon for him to have "discussions" with the paramedics when they mismanage patients. The paramedics there hate the dreaded "blue form" that's used when they mess up or don't manage a patient the way Copass wants them managed.

Despite this, nobody can argue with Seattle's cardiac arrest survival outcome data. Most of this is due to early defibrillation and extraordinary rates of bystander CPR.

 

[stoic]

i've only recently become fully aware of how deeply the politics of a hospital dictate the scope of EM at a particular hospital (to the tune of "we can't use concious sedation... the hospital requires 2 RN's to monitor the pt for 1hr post-procedure in the ED".... like sending them to the OR is really any safer.). 😱

i really hope the powers that be have the sense to pull the plug on any program with such an attitude. it doesn't do the field any favors to start a program where residents won't be trained to their full potential. we're better off with one less program than starting one with dinosaurs in charge.

(i know i'm not in the field yet.... but match willing, i will be in a couple years. i'm at home with you folks.)

 

[southerndoc]

i really hope the powers that be have the sense to pull the plug on any program with such an attitude. it doesn't do the field any favors to start a program where residents won't be trained to their full potential. we're better off with one less program than starting one with dinosaurs in charge.

Didn't the RRC revoke the accreditation of the Madigan-UW program, or maybe it was just a thread of revocation?

 

[crewmaster1]

RRC was going to revoke acccredidation if they didin't take the EM residents out of Harborview because they weren't being supervised by EM docs. So they did some time at Emanuel in Portland I think. They still rotate at the UW university hospital because it is run like a normal ED, but because of Childrens they see very little peds and because of HMC the see only very minor trauma. The Madigan program also took away the civilian spots because of the army's increasing need for EM (and all the HMC bull****).

 

[ERresponsible]

Did my undergrad at UW and MBA at Seattle U. Overall great system, but subject to same entrenched politics as most medical systems around the country.

It is bizarre that the best medical school in the country according to USNWR for 11+ years with 17 individual FP programs for 5 states doesn't have one civilian EM program.

I would think the powers that be would smack Dr. Copass a new point of view. Seattle definitely doesn't like be behind the times in anything. If this story ran in the Seattle Times, it would make big waves with the Microsoft Millionaires, Weyerhausers and Nordstroms. They would demand Harborview have EM physicians on hand in case their loved ones needed medical care.

Seattle has no shortage of smart, proactive people that know how to get things done.

 

[southerndoc]

Did my undergrad at UW and MBA at Seattle U. Overall great system, but subject to same entrenched politics as most medical systems around the country.

It is bizarre that the best medical school in the country according to USNWR for 11+ years with 17 individual FP programs for 5 states doesn't have one civilian EM program.

I would think the powers that be would smack Dr. Copass a new point of view. Seattle definitely doesn't like be behind the times in anything. If this story ran in the Seattle Times, it would make big waves with the Microsoft Millionaires, Weyerhausers and Nordstroms. They would demand Harborview have EM physicians on hand in case their loved ones needed medical care.

Seattle has no shortage of smart, proactive people that know how to get things done.

Would the millionaires of Seattle go to Harborview or to another facility? (Trauma doesn't count.)

 

[BadVB750]

Would the millionaires of Seattle go to Harborview or to another facility? (Trauma doesn't count.)

I imagine that the Docs go to the Big wigs, expect when they need a procedure that can only be done in a hospital. Then they have private suites.

 

[crewmaster1]

If this story ran in the Seattle Times, it would make big waves with the Microsoft Millionaires, Weyerhausers and Nordstroms. They would demand Harborview have EM physicians on hand in case their loved ones needed medical care.

Probably about 5 years ago there was some article in the Seattle Times. I don't remember what all it said, but I think it was written by some of the EM boarded docs at UW about HMC. It created quite a political stir and only made the political tensions worse. I wish I could have read it because I don't really know what all it said. Harborview plays the line that while all the other hospitals in the country have EM docs, they are better because at Harborview they cut out the middle man (EM) and bring the specialist right to the patient from the get go (trauma surgeon). What they fail to mention is that this is only done for level 1 traumas, otherwise all their trauma patients get a medicine attending and some surgery residents. And across the rest of the country it's done the same way where trauma surg is at the level 1 traumas, except there is an EM doc to help with all the other stuff that trauma surgeons aren't as good as (airway, cardiac, etc).

 

[crewmaster1]

Would the millionaires of Seattle go to Harborview or to another facility? (Trauma doesn't count.)

They go to Overlake Hospital (a level II on the East side of lake washington towards bellevue and issaquah where microsoft is and most people with lots of money). If they are sicker or have something weird they go to University hospital.

 

[Hard24Get]

It's all a result of people feeling threatened that others are going to take over their specialty. I spoke to an EM attending at UPenn who did a critical care fellowship after his residency. He now spends 75% of his time in the ED, and 25% in the SICU. That's a place that gets it.

I know who you're talking about! I worked with him in both places. He is such a master, I blush when I see him. Kind of my idol.... 😍😳

 

[GeneralVeers]

How can they have an EM residency with only 4 EM-boarded faculty? The RRC guidelines state that residents can ONLY be supervised by EM-boarded faculty while in the ED. 4 faculty members are not sufficient to provide 24-hour daily supervision.

 

[mikecwru]

How can they have an EM residency with only 4 EM-boarded faculty? The RRC guidelines state that residents can ONLY be supervised by EM-boarded faculty while in the ED. 4 faculty members are not sufficient to provide 24-hour daily supervision.

No, there is a ratio (either 1:2 or 1:3, can't remember) that a residency has to meet. They do not have to all (or even a majority) be boarded.

mike

 

[Apollyon]

No, there is a ratio (either 1:2 or 1:3, can't remember) that a residency has to meet. They do not have to all (or even a majority) be boarded.

mike

Yeah, just the "core faculty" have to be EM-trained/boarded.

 

[GeneralVeers]

We're told that when working in the ED the RRC requires direct supervision by a boarded person. They go to great lengths to make sure that the few non-boarded people don't work with residents. Additionally when we're at the peds hospital, we're told we cannot work with anyone not peds-EM trained.

Our PD says this is an RRC guideline. Is this in fact the case? (not that I want to work with non-boarded people).

 

[southerndoc]

We're told that when working in the ED the RRC requires direct supervision by a boarded person. They go to great lengths to make sure that the few non-boarded people don't work with residents. Additionally when we're at the peds hospital, we're told we cannot work with anyone not peds-EM trained.

Our PD says this is an RRC guideline. Is this in fact the case? (not that I want to work with non-boarded people).

We also have similar requirements. We cannot work night shifts in our peds ED because fellows sometimes work as attendings during the night.

 

[DOnut]

http://www.acgme.org/acWebsite/RRC_110/110_guidelines.asp
(we have been told the same thing as well. Seems like it's true)

Qualifications for Emergency Medicine Faculty

All emergency medicine faculty supervising emergency medicine residents on emergency medicine rotations must be board certified by the American Board of Emergency Medicine, or have appropriate educational qualifications in emergency medicine. Examples of educational qualifications acceptable to the RRC include:

Certification by the American Osteopathic Board of Emergency Medicine
Certification by a subspecialty board sponsored or cosponsored by the American Board of Emergency Medicine
Recent residency or fellowship graduates actively working toward certification by the above boards

Additionally, faculty providing supervision to emergency medicine residents on emergency medicine rotations must have appropriate qualifications relative to the patient population for which they provide EM resident supervision. For example, a faculty member board certified in pediatrics and pediatric emergency medicine would be qualified to supervise EM residents on pediatric cases, but not adult cases.

 

[igcgnerd]

😱I'm sorry after reading the original post I had an aneurysm (not really but I'm making a point). Now when I go into the emergency department where i work, barely conscious, I will look at the lab coat of the attending treating me and I will see: Dr. Joe Shmoe FACEP, and all will be well with the world😉.

 

[mikecwru]

We're told that when working in the ED the RRC requires direct supervision by a boarded person. They go to great lengths to make sure that the few non-boarded people don't work with residents. Additionally when we're at the peds hospital, we're told we cannot work with anyone not peds-EM trained.

Our PD says this is an RRC guideline. Is this in fact the case? (not that I want to work with non-boarded people).

I believe we have only one person who is not boarded in EM (IM/critical care trained) but spent their entire career in the ED. That person staffs.

We also have a more recent peds graduate that can only staff pediatric cases and thus only works in our urgent care.

A local hospital is trying to start up a residency. They have several faculty but were delayed because they didn't have enough proper faculty.

Maybe they require almost all to be boarded but the 1:3 ratio is for residency trained and boarded.

mike

 

[NeuroSync]

We are all really pissed off that there is no residency here, but even if they were able to get one together in time for my class (which, honestly, seems impossible given the attitudes), I wouldn't stay...

 

[BKN]

Maybe they require almost all to be boarded but the 1:3 ratio is for residency trained and boarded.

mike

The ratio is 1 core faculty per 3 residents. A core member is one who does no more than 28 clinical hours weekly and devotes the rest of their time to teaching/academic endeavors. For most programs there will be many non-core faculty as well, because in addition there is a coverage guideline. I believe it's <4.5 patients/ faculty duty hour. Most places are ranging that down to as low as 2.5 or close to normal production in a non-residency ED.

 

[NeuroSync]

HMC is moving in the right direction, for sure. They are hiring EM Boarded physicians for the ED. The problem is that the specialists still handle just about everything that comes in. It is a system that works for that hospital, but most places do not have their resources, and they need to be able to train ER docs to handle a lot of what is at present immediately consulted out. There is a ton of great pathology and really great physicians and staff. It's really sad that there is no residency there. I'd do just about anything to change the situation, but I don't think things will change even in the next five years. We shall see. Ergo, I'll be off to "sample" other programs early next year. If I can do anything to make a change for those who will follow, I will...

 

[southerndoc]

The ratio is 1 core faculty per 3 residents. A core member is one who does no more than 28 clinical hours weekly and devotes the rest of their time to teaching/academic endeavors. For most programs there will be many non-core faculty as well, because in addition there is a coverage guideline. I believe it's <4.5 patients/ faculty duty hour. Most places are ranging that down to as low as 2.5 or close to normal production in a non-residency ED.

BKN, is it 4.5 or 6? I thought I read somewhere that it was 6/hr (I remember being amazed it was that high).

 

[Pelivar]

It's all a result of people feeling threatened that others are going to take over their specialty. I spoke to an EM attending at UPenn who did a critical care fellowship after his residency. He now spends 75% of his time in the ED, and 25% in the SICU. That's a place that gets it.

He went to Christiana. We've had a bunch of people do critical care after residency and practice doing both. I believe he did his fellowship at shock trauma.

To the OP, that is a truly scary story. I cannot imagine being one of the graduates of that program. When they go out into the community after residency they are going to be totally unprepared for the real world. Already in the first month after graduating residency and working in the community I've had tons of sick, sick patients and times when no consultants were available for big procedures and it was on me (transvenous pacers, thoracotomy, intubations, reductions, etc.) I hope the RRC does not let this go forward. It would be a big step back for our specialty. Hopefully EMRA/AAEM/ACEP will get involved in this as well. Especially as we will be in Seattle for ACEP this fall.

 

[crewmaster1]

To the OP, that is a truly scary story. I cannot imagine being one of the graduates of that program. When they go out into the community after residency they are going to be totally unprepared for the real world. Already in the first month after graduating residency and working in the community I've had tons of sick, sick patients and times when no consultants were available for big procedures and it was on me (transvenous pacers, thoracotomy, intubations, reductions, etc.) I hope the RRC does not let this go forward. It would be a big step back for our specialty. Hopefully EMRA/AAEM/ACEP will get involved in this as well. Especially as we will be in Seattle for ACEP this fall.

The good thing for the current residents in the Madigan program is that they do the majority of their training outside of Harborview (by far most of their training). So, they are getting to see and do stuff at UW ED, Childrens, and Madigan Army Medical Center which is a level 2 with occasional level one capabilities depending on deployment levels. I think the residents get a good education, it is just that MAMC is 50+ miles from UW, making it hard from a program to split their time 1/2 and 1/2 between the two.

I'm hoping ACEP in Seattle will help raise a lot of questions and get things stirring. I'm an intern at U Cinci who really wants to go back and be part of a new Seattle program! We'll see what happens.

 

[NeuroSync]

The good thing for the current residents in the Madigan program is that they do the majority of their training outside of Harborview (by far most of their training). So, they are getting to see and do stuff at UW ED, Childrens, and Madigan Army Medical Center which is a level 2 with occasional level one capabilities depending on deployment levels. I think the residents get a good education, it is just that MAMC is 50+ miles from UW, making it hard from a program to split their time 1/2 and 1/2 between the two.

I'm hoping ACEP in Seattle will help raise a lot of questions and get things stirring. I'm an intern at U Cinci who really wants to go back and be part of a new Seattle program! We'll see what happens.

As you can imagine, those of us in school now at UW are concerned about this. I've been told that there is NO WAY that there will be a program here in time for us (MS-3), and probably not for a couple of years after we are long gone...

Bottom line: don't get your hopes up.