Thread: EM Residency

Hello friends,

I have a question that I am hoping recent grads who obtained an EM residency or people knowledgeable might be able to answer. I am in my 3rd year at SGU. I saw on the OCG site an EM presentation for residency that says in order to be competitive an applicant should be in the top 3-6% of your class and have a GPA between 3.53 and 3.73 among a few other criteria. My question is this- I finished basic sciences with about a 2.6 GPA, studied well for the Step 1 and got a 230 on it. I am assuming that because of my basic science GPA my class rank will be well towards the bottom. Are these things going to be too poor for my decent step 1 score to overcome?

lol, actually, I would love to have this debate continue....as long as it stays civil and within the TOS, so feel free to post Paddy! as you know, I'm an ex-medic....

Originally Posted by PaddyMelt

replied via PM to avoid the moderators from ending an actually useful and interesting thread b/c they subjectively feel its not related to EM.

i actually would like to see your reply because i agree 100% with groove

Originally Posted by kananaskis_girl

lol, actually, I would love to have this debate continue....as long as it stays civil and within the TOS, so feel free to post Paddy! as you know, I'm an ex-medic....

As was I, and I would also love to see this continue

Due to overwhelming demand of seeing me put my foot in mouth once again . . . from my outbox to yours:

Regarding your second post, I totally agree that ED physicians have to be careful about what they wish for regarding MLP's and their roles in the ED/fast-track/whatever you wanna call what they're doing. Part of the problem is, no doubt, our inability to have nearly enough staff covering any department nowadays. And the inability of ED residents to physically be trained fast-enough, given the overwhelming shortage of residency-trained physicians. I mean, even at the SGU rotation at Lincoln (the Bronx) - huge residency (albeit lacking in trauma, amongst other things) - they are staffing half their department with non-EM trained b/c no one else wants to go there.

And I definitely see your point about non-urgent vs. urgent being defined by the 'eye-of-the-beholder'. But, its hard for me to fully agree (at 3.00am, PICU call) with what you're saying. I mean, emotionally, it makes sense to be upset and feel like we're seeing more than our fair share of patients who truly have nothing wrong with them, and could have easily, in our eyes, been seen in the AM - or a few days, for that matter - by their PCPs/OB's/etc. But, its also easy for us to do that since we've been trained to know the difference between what is truly "urgent" vs. not.

My program sounds very similar to yours - tons of trauma, surrounding urban environment is desolate, jobless, severely under-educated (adult literacy rate is <50%)... and we see everything under the sun. Our patient population is not so fortunate in life. They don't know the difference between something urgent and something non-urgent. Take your example about the DUB - your 30-something, un-educated woman, with no job and no foreseeable prospects, no insurance and no money has been bleeding for 3 days; her history includes some cramping and socially she admits to unprotected intercourse. So, your exam includes a negative preg, no evidence for STD's and you diagnose DUB. I'm with you, feels totally non-urgent and not worth your time - but do you see how that's absolutely urgent and borders on emergent? If she's pregnant, the whole scenario changes - but she couldn't afford to buy the test from Walgreens, and she doesn't realize how little blood this actually was, and you quickly and easily diagnose her given your medical degree that helps you determine she's not suffering an acute emergency and can safely be referred to the free clinic...

And one major difference between your hospital and mine - we have a horribly bad business gimmick, in which all patients are seen by an MD within a very short amount of time, regardless of chief complaint. One of the (very, very few) upsides is that I can "drive-by" the chronic back pain, evaluate "sick vs. not sick" in 30 seconds and move directly to the chest pain to spend my time getting an accurate H&P. The back pain is happy he was actually "seen" by the doctor, and he can wait for his toradol shot and discharge paperwork. And ALL of those sicklers that you chronically treat - we give PO or IM meds and send them home; nothing IV, and no further tests unless they have some other concerning symptoms, which works quite nicely.

Finally, to clarify, medical bills that aren't in collections or are under $100 do not go onto your FICO report. However, most medical offices/billers will send your bill to collections quite rapidly to the collections agency. This is why the number one cause of bankruptcy in the US is due to medical bills (Research: Medical Bills Leading Cause of Bankruptcy). We can debate all the issues about that later, but the immediate on people's FICO score doesn't seem to be lessening the long-term problems.

Anyway, as I said in my reply to Groove last night, I was on ICU call, went to evaluate a patient on the floor and the vast-majority of my ramblings were lost when I came back. So, you get the shortened, post-call version. Please note that I also requested a stiff drink. Flame on . . .
Cheers, Paddy.

Originally Posted by PaddyMelt

Due to overwhelming demand of seeing me put my foot in mouth once again . . . from my outbox to yours:

Regarding your second post, I totally agree that ED physicians have to be careful about what they wish for regarding MLP's and their roles in the ED/fast-track/whatever you wanna call what they're doing. Part of the problem is, no doubt, our inability to have nearly enough staff covering any department nowadays. And the inability of ED residents to physically be trained fast-enough, given the overwhelming shortage of residency-trained physicians. I mean, even at the SGU rotation at Lincoln (the Bronx) - huge residency (albeit lacking in trauma, amongst other things) - they are staffing half their department with non-EM trained b/c no one else wants to go there.

And I definitely see your point about non-urgent vs. urgent being defined by the 'eye-of-the-beholder'. But, its hard for me to fully agree (at 3.00am, PICU call) with what you're saying. I mean, emotionally, it makes sense to be upset and feel like we're seeing more than our fair share of patients who truly have nothing wrong with them, and could have easily, in our eyes, been seen in the AM - or a few days, for that matter - by their PCPs/OB's/etc. But, its also easy for us to do that since we've been trained to know the difference between what is truly "urgent" vs. not.

My program sounds very similar to yours - tons of trauma, surrounding urban environment is desolate, jobless, severely under-educated (adult literacy rate is <50%)... and we see everything under the sun. Our patient population is not so fortunate in life. They don't know the difference between something urgent and something non-urgent. Take your example about the DUB - your 30-something, un-educated woman, with no job and no foreseeable prospects, no insurance and no money has been bleeding for 3 days; her history includes some cramping and socially she admits to unprotected intercourse. So, your exam includes a negative preg, no evidence for STD's and you diagnose DUB. I'm with you, feels totally non-urgent and not worth your time - but do you see how that's absolutely urgent and borders on emergent? If she's pregnant, the whole scenario changes - but she couldn't afford to buy the test from Walgreens, and she doesn't realize how little blood this actually was, and you quickly and easily diagnose her given your medical degree that helps you determine she's not suffering an acute emergency and can safely be referred to the free clinic...

And one major difference between your hospital and mine - we have a horribly bad business gimmick, in which all patients are seen by an MD within a very short amount of time, regardless of chief complaint. One of the (very, very few) upsides is that I can "drive-by" the chronic back pain, evaluate "sick vs. not sick" in 30 seconds and move directly to the chest pain to spend my time getting an accurate H&P. The back pain is happy he was actually "seen" by the doctor, and he can wait for his toradol shot and discharge paperwork. And ALL of those sicklers that you chronically treat - we give PO or IM meds and send them home; nothing IV, and no further tests unless they have some other concerning symptoms, which works quite nicely.

Finally, to clarify, medical bills that aren't in collections or are under $100 do not go onto your FICO report. However, most medical offices/billers will send your bill to collections quite rapidly to the collections agency. This is why the number one cause of bankruptcy in the US is due to medical bills (Research: Medical Bills Leading Cause of Bankruptcy). We can debate all the issues about that later, but the immediate on people's FICO score doesn't seem to be lessening the long-term problems.

Anyway, as I said in my reply to Groove last night, I was on ICU call, went to evaluate a patient on the floor and the vast-majority of my ramblings were lost when I came back. So, you get the shortened, post-call version. Please note that I also requested a stiff drink. Flame on . . .
Cheers, Paddy.

Hey, no flames here Paddy and we'll def have to share that drink at ACEP next year if you're going! Sorry that I didn't respond to PM or on here sooner but been out of town on vaca and now finishing a few shifts and day off tomorrow.... so, as I'm sitting here drinking my tequila bloody mary, wishing I had had a perdomo lot 23 cigar.... I'll take a few minutes to respond.

Honestly, I don't have much extra to say, we just have a divergence of opinion on the purview and future obligatory function of Emergency Department services in this country. As I said... current views show a dichotomy of opinions on the subject, but I don't favor opening the floodgates of ED services to treat "perceived" emergencies and broad sweeping definitions of semi-urgent care. I'm not arguing that we are capable of seeing low acuity stuff and easily treating/discharging. Any physician is capable of this. I disagree that our EM training and subjective/objective perspicacious intuition for quickly determining "sick" vs "non-sick" helps us treat low acuity pt's any better than another physician in X specialty. The FP can treat a rash, laceration, skin infection just as easily as you or I can and can determine if the pt is suffering from any concomittant cellulitis, extensive abscess or soft tissue infection, etc.. that would require ED evaluation. The same goes for an otitis media, viral pharyngitis, you name it... Are there some uncommon emergent complications from some of these conditions...certainly, but a PCP and most physicians have a gestalt of their own.... after all, if they didn't, they would never send their pt to the ED, so I disagree that we are better in treating these low acuity pt's. Is it easy work? Sure. Does it pay? Sure. It's easy to take the attitude of "hey I don't mind seeing all of this crap because it's low stress, I'm capable, and I'm getting paid well to do it...." This is a cop out in my opinion. What's the overall purpose of our specialty? We should be "experts" in recognizing, intervening, and managing most emergent or acute presentations of pathology spanning all specialties. We should also be experts in resuscitation and airway management. I'm not an internist, don't know jack about most chronic medical diseases or their management, have the utmost respect for IM guys, but I can recognize DKA,COPD exac,CHF exac, PE, etc.. and manage it with one hand tied behind my back. I'm not an intensivist, but I can manage sepsis just as easily. I'm not a cardiologist, but I can do the same with NSTEMI, STEMI, recognize 3rd deg block and float a transvenous pacer just as well as the cards fellow. I'm not an anesthesiologist, but can fiber optically NT awake intubate a horrible angioedema pt with a bronchoscope with facile, or cric if necessary. HTX, PTX? No problem, chest tubes with ease or even do an ED thoracotomy if I need to on the GSW that just lost pulse. The list goes on along with the specialties. This is what we're trained to be able to handle. Critical care medicine and emergencies in the ED. We're trained to quickly recognize, intervene, stabilize, resuscitate, acutely manage and pass on to the specialist. Now... how facile would an anesthesiologist be with intubations if he only did 1 a week or month for that matter? Cardiologist that only sees a STEMI once every 2 months? If you water down what we see in the ED with an overwhelming low acuity pt population, your skills will suffer along with your confidence. That's why you have guys in rural ED's that forget how to RSI, place chest tubes in the liver or the diaphragm and do other crazy stuff. They probably spend 95% of their time seeing low acuity, clinic type medicine and lose their EM skill set. There's a place for the non-emergent, even semi-urgent, clinic type pt presentations that possibly couldn't wait for a PCP appt, and it's called an urgent care clinic. These pt's simply don't need to be in an "emergency department" with emphasis on "emergency".

No, I don't need to see every vag bleeder with irregular periods and cramping, or vague pelvic complaints requiring expensive tests where all she wanted was a UPT to see if she was pregnant and didn't want to PAY for the test at the local CVS/Walgreens... Nor do I need to see the UTI/BV girl c/o dysuria and vaginal discharge along with the guy with genital warts and hemorrhoids. You're trying to turn my female pt into a r/o ectopic, or IUP/incomplete abortion, etc.. and that's great since our differential is much different than other physicians where we are supposed to r/o the most life threatening differentials first before moving onto the most likely dx, but I simply don't want or need to see that stuff (Even if I'm getting paid well to do it!). You and I both know that many of these pt's, along with the epistaxis, viral URI's, etc.. simply don't need to be there. You're list of emergency differentials doesn't make you any more efficient at treating these people because...guess what? their likelihood of having an emergency was almost nill. They are coming in droves to the ED because it's quick, easier than scheduling an appt with the OB doc or PCP and most of all.... free. Health care is never going to be saved if we encourage this type of blatant misuse of the ED. These are pt's that many times we have never seen or have any medical records on... We essentially are seeing them one time and have one chance to make damn sure they aren't having an emergency. It encourages shotgun workups and over testing, over use of diagnostic studies to basically "save our ***" from litigation. This country needs primary care providers to function as gatekeepers. Pt's going to EDs for anything and everything results in drastically more aggressive workups, regardless of acuity level. Pt's being bounced around among specialists amounts to the same. If pt's learn to just "go to the ED for anything and everything because they'll always see you...." what is to encourage them to see their regular doctor? Nothing. Overcrowding will grow and we aren't pumping out enough EM docs to supply the demand, so you are again... stuck hiring mid-level providers to see the low acuity pt's. You're losing your skill set and doing nothing to earn respect among your specialist colleagues who can go moonlight in a community ED and function just as well as you can because 90% of what they are seeing is basic medical management on low to medium acuity pt's. If they run into trouble, they call a surgeon, anesthesiologist or someone else to handle it. That type of function fits a derogatory term we've all heard before... the EP who is basically a "glorified triage nurse" giving specialists the impression "hey... anybody can do this stuff." It does nothing to earn you credibility and respect among your peers or earn respect for your specialty. We need to make more of an effort to divert pt's to their proper destination and I argue that pt's need to be turned away from the ED more often and referred to PCP's, FQHC clinics, urgent care clinics, you name it. Am I losing some potential business in doing this? Sure... but I'm trying to save the future of our specialty and the future of primary care and decrease overall health care costs without losing a tremendous amount of medical care to empowered nurses who have largely gained independent practice through legislation by politicians, are funding biased outcomes based research studies and have organized an extremely effective and powerful state and federal legislative lobbying force that is directly influencing current and future health policy formation in this nation.

We are losing primary care and the government is leveraging MLP's to "fill the void". This will have dramatically negative impacts on the future of medicine in this country in my humble opinion and further degrade the prestige, respect and autonomy of our role as physicians. I see overuse of the ED as help in facilitating this overall deleterious effect, and again... it is a complete disservice to our colleagues and a twisted distortion of what our specialty was conceived to accomplish. We just got EM as an approved specialty 40 years ago... I don't want to lose that in another 40, regardless of whether I'm old and gray (76?, yikes...) and rich from the profits, already retired, just in time to see the DNP's take over.

The best thing possible for EM is to see more emergencies, less overcrowding, more use of primary care, more referral to proper medical services and decreased bureaucracy that ties my hands behind my back and forces me to manage algorithmically in order to get "paid" i.e. medicare billing (all because the ED bill, and medical care for that matter, costs so damn much to offset the non-payers!). As for ED bills and FICO, they aren't factored into the revolving-credit utilization ratio. Yes, it will affect it if it's sent to a collection agency, but the hospital has to decide whether paying a collection agency for the 20th time to collect on a pt who has never paid the 19 previous times is worth the time, money or effort. Regardless, again.... the pt has the most incentive, initially and potentially indefinitely, to pay on everything OTHER than the medical bill which I think is just ridiculous. Lots of tangents and ranting in there, but.....well, there you have it.

The sad irony is that our current health care system makes the most profit off releasing pt's from the hospital and letting them get acutely ill all over again requiring ED eval, invasive procedures, admission, extensive work ups and lengthy management, discharge....poor continuity of care...non compliance...decompensation, rinse and repeat, ad nauseum. We should be leveraging MLP's to go out to pt homes and do wellness checks on pt's, check on medication compliance, pt education, etc.. to ensure that they stay out of the hospital and continue to get well, NOT turning them into primary "docs", but that's another discussion altogether.

Another thing I find ironic, is that a FP can do a 1 yr fellowship in "emergency medicine" for certification of additional training in an ED so that he can staff a more rural community ED location that probably doesn't see a ton of high acuity pt's and tends to see more bread and butter FM clinic pt presentations, and if he gets tired of working in the ED, he can always work in a clinic setting... yet if an EM doc wants to work in the same place, and have the same options, he/she can't take a 1-2yr FM fellowship to do the same thing. WTH? Someone please explain that one to me.

Originally Posted by Groove

The sad irony is that our current health care system makes the most profit off releasing pt's from the hospital and letting them get acutely ill all over again requiring ED eval, invasive procedures, admission, extensive work ups and lengthy management, discharge....poor continuity of care...non compliance...decompensation, rinse and repeat, ad nauseum. We should be leveraging MLP's to go out to pt homes and do wellness checks on pt's, check on medication compliance, pt education, etc.. to ensure that they stay out of the hospital and continue to get well, NOT turning them into primary "docs", but that's another discussion altogether.

actually, this has gone away in some areas and is going to be going away in many more. If a patient is released early and develops, say, a "preventable post-op complication" (determined by government standards) requiring re-hospitalization, the hospital picks up the tab....medicare and medicaid will not pay for the readmission. And a lot of insurance companies are going this way as well, using the government standards. And they're becoming broader as we speak to what they deem a preventable complication....

Originally Posted by kananaskis_girl

actually, this has gone away in some areas and is going to be going away in many more. If a patient is released early and develops, say, a "preventable post-op complication" (determined by government standards) requiring re-hospitalization, the hospital picks up the tab....medicare and medicaid will not pay for the readmission. And a lot of insurance companies are going this way as well, using the government standards. And they're becoming broader as we speak to what they deem a preventable complication....

I think those are def steps in the right direction... Let's just hope these policies can be constructed properly. The problem with blanket policies such as the above with medicare/caid refusing bills based on high re-admission rates is that it's often put into effect by bureaucrats and policy writers attempting to correct a problem without offering any solution or having any insight into the root issues at hand. Now given, one could argue that it's not their problem because these are often issues at a regional, state or even individual hospital level, but I think it would still help to have some solutions offered or even implemented at a state legislative level (I'm even nervous in saying that...but...). The danger of just suddenly chopping funding for re-admission within 30d is that the hospital is forced to quickly implement policies to help prevent this from happening and you and I both know these things take a lot of time. Otherwise, the hospital is in danger of bankrupting itself and/or shutting down which helps nobody. They're more than likely to recoup the loss by nefarious billing in other ways on their paying customers, or...even easier...chopping our salaries or bonuses! That's always easier, right? As if it's my fault the pt went home and didn't fill their Rx or follow up with their appts. Why don't we supplement some of these "advanced" NP curriculums with some of the things I mentioned such as wellness checks, home visits, pt education and keep these people out of the hospital. I mean, check out these NP curriculums...

NURS 840 Scientific Basis for Clinical Reasoning?
NURS 826 Finance and Economics of Health Care?
NURS 806 Research Methods?
NURSE 827 Health Policy?

Are you kidding me? This is what they are being taught to make make them "equal" with the MDs?

I've got news for the nurses, why don't you scrap most of those fluff courses that you don't need and will never use. (What NP needs to learn research methods and economics? Do you really need a course to teach you the BASIS of clinical reasoning? Good grief....) Replace or augment some of those courses with some of the above mentioned and do us all a favor in helping keep our pt's out of the hospital. You'd do a hell of a lot more good than sitting in a class snoring through some of these classes or twittering to your CRNA friend about how easy all this "doctor" stuff is that you are told you are learning.

KG,

Found an interesting article on this after you brought it up... Check it out. NEJM Want to see something depressing? Check out Figure 1.

Where is EM going, from SDN

Where is emergency medicine going? | Emergency Medicine | Student Doctor Network