What type of program would be right for me?

[MrBling]

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I'm curious for some input..

I'm gearing up to apply to an EM residency this year.. but something has been nagging at me (this started with a statement in my PS about patients who don't have primary care who come to the ER.. i was debating if i should remove it since it may be a touchy subject since some EM docs don't like that these patients are taking up a scarce resource away from people who may really need it.. makes sense i guess)

With a background in business and an interest in operations efficiency, I'd like to get exposure to progressive programs that might be looking at ways to address this from an operational standpoint.

Anyone aware of programs out there that I might want to look at?

 

[VentdependenT]

I'm curious for some input..

I'm gearing up to apply to an EM residency this year.. but something has been nagging at me (this started with a statement in my PS about patients who don't have primary care who come to the ER.. i was debating if i should remove it since it may be a touchy subject since some EM docs don't like that these patients are taking up a scarce resource away from people who may really need it.. makes sense i guess)

With a background in business and an interest in operations efficiency, I'd like to get exposure to progressive programs that might be looking at ways to address this from an operational standpoint.

Anyone aware of programs out there that I might want to look at?

Isn't that what the fast-track area is for? At least around me it is.

 

[dlung]

I'm curious for some input..

I'm gearing up to apply to an EM residency this year.. but something has been nagging at me (this started with a statement in my PS about patients who don't have primary care who come to the ER.. i was debating if i should remove it since it may be a touchy subject since some EM docs don't like that these patients are taking up a scarce resource away from people who may really need it.. makes sense i guess)

With a background in business and an interest in operations efficiency, I'd like to get exposure to progressive programs that might be looking at ways to address this from an operational standpoint.

Anyone aware of programs out there that I might want to look at?

That's an odd statement up there--can't quite tell what your opinion is.

In any case, ER crowding has been an issue in EM for years, so YES, there are people out there who invest a lot of time and research into operations and flow. Just do a lit search on the topic to figure out where people work. Places with health policy fellowships would be worth looking into. Also, programs with university affiliations (obviously) would potentially have the business/policy school faculty to work with.

 

[dlung]

Actually just got a mailer from the EMA-USC admin fellowship, which reminds me that there are a handful out there...

 

[MrBling]

Thanks for your response dlung, my opinion is actually that i like to take the opportunity for some basic patient education.. even if its not directly related to their chief complaint.. especially if sometimes they are there for a non acute complaint (basically figure out why they are there.. what their concerns are and why they felt they need to come in.. ill talk alittle about their disease process and some red flags that they should look for that are truely emergent).

Perhaps I'm still green.. but I've gotten some flak from attendings for not sticking with the chief complaint (and 'looking' for more than there is), i guess in the ER its important to move the patients.. but if I know they don't have good followup or a PCP, i usually take a couple of extra minutes to do a complete exam and ask a few extra questions.. might not have that luxury as a resident or attending though... thats why i'm wondering if there is a more efficient way to triage these patients to make sure they get the care they need (even if it is just some simple education or a more complete exam) on an operational level.

I can see the argument that by doing this you are encouraging this behavior.. but on the other hand.. people showing up to the ER with non acute problems/ no PMD is a real problem.. a few minutes of education will hopefully alleviate patient anxiety and perhaps decrease the load on the system with non emergent visits.

 

[AmoryBlaine]

I hope I'm not misinterpreting your question, but it seems like you're saddling yourself with a catch 22.

Programs that have increased numbers of patients in the ED for "primary care" will have higher censuses and therefore you will probably need to spend less time with each patient.

Also make sure that you define to yourself what you mean by these phrases. I am of the belief that we do almost no primary care in the ED. There is a huge difference between ambulatory complaints (knee pain, back pain, simple lacs) and primary care (HTN, DM, preventative screening). As an EP you are definitely going to need to know how to manage ambulatory complaints but actual primary care is useless knowledge.

Ex: I need to know how to do a good pelvic exam, I do not need to know how to manage an abnormal PAP smear.

 

[MrBling]

I hope I'm not misinterpreting your question, but it seems like you're saddling yourself with a catch 22.

Programs that have increased numbers of patients in the ED for "primary care" will have higher censuses and therefore you will probably need to spend less time with each patient.

Also make sure that you define to yourself what you mean by these phrases. I am of the belief that we do almost no primary care in the ED. There is a huge difference between ambulatory complaints (knee pain, back pain, simple lacs) and primary care (HTN, DM, preventative screening). As an EP you are definitely going to need to know how to manage ambulatory complaints but actual primary care is useless knowledge.

Ex: I need to know how to do a good pelvic exam, I do not need to know how to manage an abnormal PAP smear.

You make some good points.

I'm not proposing an alternative for primary care via the EM.. merely some patient education to help them understand their disease process and what can be expected (as normal progression) and what is emergent. I'm not out to manage their DM or their HTN.. but if complications should arise with the DM/HTN, they should be aware of the red flags where they need to come in immediately (obviously this implies advanced disease.. and this in no way reduces the need for them to be appropriately followed, which is the real issue.. and not one that I (nor any other EM) is or should be dealing with).

I guess what I am proposing is still ultimately outside the scope of EM, it just seems that there is the potential of increasing patient knowledge, reducing nonacute EM visits at the expense of a few minutes. Does this make any sense or is it too naive of a perspective?

 

[roja]

Also make sure that you define to yourself what you mean by these phrases. I am of the belief that we do almost no primary care in the ED. There is a huge difference between ambulatory complaints (knee pain, back pain, simple lacs) and primary care (HTN, DM, preventative screening). As an EP you are definitely going to need to know how to manage ambulatory complaints but actual primary care is useless knowledge.

Ex: I need to know how to do a good pelvic exam, I do not need to know how to manage an abnormal PAP smear.

An excellent, subtle and often not percieved point.

 

[AmoryBlaine]

You make some good points.

I'm not proposing an alternative for primary care via the EM.. merely some patient education to help them understand their disease process and what can be expected (as normal progression) and what is emergent. I'm not out to manage their DM or their HTN.. but if complications should arise with the DM/HTN, they should be aware of the red flags where they need to come in immediately (obviously this implies advanced disease.. and this in no way reduces the need for them to be appropriately followed, which is the real issue.. and not one that I (nor any other EM) is or should be dealing with).

I guess what I am proposing is still ultimately outside the scope of EM, it just seems that there is the potential of increasing patient knowledge, reducing nonacute EM visits at the expense of a few minutes. Does this make any sense or is it too naive of a perspective?

It's not a bad idea or a naive perspective, but a few more points.

1. We do this all the time. We're always telling people to "come back if you experience chest pain" or other similar things.

2. Regarding the "red flags" that arise in patients with the usual chronic diseases (DM/HTN): you usually don't need to educated people on what they need to do b/c everyone knows to come to the ED. People with AMIs, strokes, and dissections are probably going to come in. Ditto DKA, hypoglycemic coma etc.

3. There are always little studies on "brief interventions" published in Annals/AEM. If you are interested look for some of the data on this stuff. I for one am not a huge believer in the ED as a major educational public health venue. It's too busy and as far as I now we can't bill for "health counseling."

 

[spyderdoc]

It's not a bad idea or a naive perspective, but a few more points.

1. We do this all the time. We're always telling people to "come back if you experience chest pain" or other similar things.

And don't forget that everytime you call a clinic, pharmacy, or any other medical related phone number, there is always that disclaimer message telling all to call 911 or go to the closest ER if they feel they have a medical emergency....

Same goes for the advise lines....They tend to have itchy "send to the ER" trigger fingers as well...

 

[southerndoc]

Same goes for the advise lines....They tend to have itchy "send to the ER" trigger fingers as well...

Can't blame them given our lawsuit-happy society.

 

[EC3]

why not just do a family med residency in an impoverished area?

and not to sound cynical, but I really doubt that 10 minutes of education is going to have a lasting impact on many of the patients. when medicaid patients want you writing scripts for tylenol so that they don't have to pay $2 to grab it over the counter, that's not an education issue. and when medicaid patients call an ambulance because it's cheaper than a taxi or driving, that's not an education issue. you can't educate the unwilling or willfully ignorant.

 

[kungfufishing]

Oh, certainly they must listen to ME, however, I mean, I'm important!