Careers in Emergency Medicine

1. Careers in Emergency Medicine Eric D. Katz, MD Assistant Director EM Residency Program Washington University in St. Louis

2. 54 male with chest pain and SOB Who do you call/see? • Cardiologist • Emergency Physician • Internist • Family Practitioner

3. 9 year old who fell down Who do you call/see? • Pediatrician • Family Practitioner • Emergency Physician • Neurologist

4. 19 female feeling “depressed” Who do you call/see? • Emergency Physician • Psychiatrist • Internist • Pediatrician

5. I will not sell you a bill of goods The right field for you is only determined by you!

6. 3 Major Topics • Is EM right for you? • How do I choose the right residency? • How do I get the residency to choose me?

7. What is EM all about? • Stabilization • Initial Diagnosis • Initial Disposition • Team work • Patient care when it’s needed VARIETY!!!

8. Variety – the good partYou never know what is coming through the door next. Pathology vs. “Bread and butter” Surgical vs. medical Pediatric vs. geriatric

9. Variety –the bad part “You never know what is coming through the door next.” Chest pain Psychiatry OB/Gyn days

10. Advantages of careers in Emergency Medicine • Hours: • Academic: 28-36 hours per week • Private: 32-40 hours per week • No beepers or office headaches! • Minimal catering to referral sources • Young field with easy route to leadership. Room for a variety of interests in research, administration, education and private enterprise.

11. Disadvantages of careers in Emergency Medicine • Night and holiday shifts • Patient loyalty • Patient satisfaction ≠ appropriate care • HOSPITAL overcrowding – safety net • Physician contract groups – business • “Life in the Fishbowl”

12. EM Subspecialty Training • Pediatric EM – EM or Peds • Sports Medicine – EM, IM, FP, Peds, Orthopedics • Toxicology – EM, Peds, FP, IM • Emergency Medical Services [EMS] • Disaster Medicine • Cardiovascular • International Health • Research • Administration

13. Emergency Medicine Research • Where are most acute care trials getting their patients? • EM research knows few boundaries • Stroke and neuro-protection • Resuscitation • Acute cardiac syndromes • Head injury and trauma • Pain management • Infectious disease

14. Academic Start at $150K plus strong benefits Mean salary: $180K Very high job security Community Start at $180-240K plus variable benefits Mean salary: $240K Variable security Follow the Money

15. Who goes into EM? • “I loved every rotation but felt too limited by every field until my EM rotation.” • “I’ve been an EMT for 12 years and knew from birth that I wanted to be an EP.” • “I really like to ski and want the lifestyle.” • “I don’t want to be tied to a practice.” • “I have lots of other interests”

16. Personality Types for EM • Working with the underserved • Enjoys fast pace – “first on the scene” • Tends to be drawn to the outdoors • Interested in time for family • Team oriented work style • International health/travel • “Work hard – play hard” club

17. The Big Myth Burnout in EM is as high as 15% per year The truth: EM BOARDED MD’s have the same burnout rate as every other specialty. 5% per year (EM, IM, Peds, Surgery)

18. Myth #2 “Why would you want to be half of a doctor when you can be a whole one?” The truth: Highly competitive specialty, experts in critical care, resuscitation, trauma and field medicine.

19. Myth #3 “You can do another residency and moonlight in an ED if you want to” • Boarded EP’s are cost-efficient, faster, and better than any other physician in an ED. (proven) • Times have changed • Training and certification count • Fewer opportunities for those not trained

20. Emergency Medicine Residency

21. The Training • Community vs. Academic • PGY 1-3 vs. 1-4 vs. 2-4 • Program size (18-50) • Patient mix and acuity • Location • The best program in the country?

22. How difficulty is it to get into EM? • 1747 applicants for 1242 spots last year • 7 programs didn’t fill in last year’s match (13 spots) • International medical graduates • Osteopaths • Prior Training • Previously failed to match Bottom line: it isn’t as bad as it seems!

23. The basics… • Residency is doable and available • Find the right program for your strengths and needs • Pick your program carefully • you will spend half of your life in the hospital for the next 3-4 years. • Emphasis on lifestyle with lots of room for academic and leadership pursuits.

24. Residents • Support • Social life • Teaching and learning • Camaraderie • Talk with residents!!!

25. EM Faculty • Experience levels • Supportive? • Teaching style? • Bedside teaching quality? • Supervision vs. autonomy? • Residency leadership -- supportive?

26. Institution • Presence of other residency programs • Primary and affiliated sites? • Financial stability • Radiology and ancillary services • Informatics & Computer resources • Hospital Admin & Medical records

27. Support of Emergency Medicine • EM resources • Division vs. Department? • Role in trauma / airways? • Procedural sedation agents? • Admitting privileges? • Holding orders?

28. Trauma • Volume? • Type? • Organization? • Competence?

29. Pediatric EM • Volume? • Dedicated pediatric ED? • Peds EM faculty? • Off-service rotations? • Pediatric resuscitations? • Airway management?

30. Other Staff Nursing/Ancillary • Experienced? • Adequate numbers? • Rapport with residents? Consultants • Team players? • Teaching? Medical students

31. Program Format • 3 vs. 4 years • Research opportunities • Patient population • Volume? • Acuity? • Off-service rotations -- purpose, quality, role? • County vs. University • Single vs. multiple training sites

32. Absolute Truths • EM is the only specialty with multiple training pathways • Successful ABEM certification is the only hurdle that really matters • Everyone has an opinion • There is no “best” answer

33. Historical Context • Early residency training was set at 2 years • Programs expanded to 3 years in the 1980s • ABEM requires a minimum of 36 months of training in EM in order to sit for the certification (board) examination • The board initially intended 3 years following an intensive in-patient year (PGY2-4) • Market forces came into place • Concerns about competition for transitional slots caused many to embrace a PGY1-3 format

34. The Bottom Line - 2004 • PGY 1-3; 100 75% • PGY 1-4; 16 12.5% • PGY 2-4; 16 12.5% Why would an applicant choose to invest in an “extra” year of training? Why would an institution design a longer than required program of training?

35. 3-Year Format • Finishing sooner makes sense • Able to work independently • Fellowship and sub specialization await • Financially sound • More income - $100000 more than as resident • Start repaying debt sooner • “you’ve waited a long time already”

36. 3-Year Format • Job competition from 4 year graduates • Which would you hire? • Confidence gap (real and perceived) • Steep learning curve “on the job” • Caught up after 1 year in “practice” • Harder to get academic positions • 3 year grad can’t be faculty at 4 year program • “what do you bring to the institution?”

37. 3-Year Format • Limited elective time • Minimal experience • “Gotta learn everything in 3 years” • Constrained by curricular requirements • Little opportunity to explore other areas within emergency medicine • “I’m not sure what I want to do!”

38. 4-Year Format • More “seasoned and confident” • Time to address areas of “relative weakness” • Tailor education to future career goals • Sheltered learning environment • Opportunity to do procedures, teach and supervise • Develop your own “style” • Manage ED flow • Impact of CMS “teaching rules”

39. 4-Year Format • Scholarly productivity increased • Electives • Everyone is different • Develop areas of “minor expertise” • What proportion really accomplish this? • Most sub specialty areas within EM don’t have a certification pathway • Do you need to do a formal fellowship? • Unlike medical specialties limited financial benefit

40. 4-Year Format • Financial idiocy for hospital • $65000/senior in PGY4 year • Resident lost wages • Loan repayments loom • Moonlighting isn’t the “same” • If really academically geared… • 3 years + fellowship is more “efficient”

41. Certification Pass Rates • No difference in In-service scores • No difference in certification exam pass rates • The “core content of EM” can be mastered in 3 years • The results implies “competency” but the test doesn’t evaluate real-time clinical interaction

42. 3 vs. 4 Year Training Tracks • All approved programs will provide trainees with a solid foundation in the practice of Emergency Medicine • What is the program’s specific mission statement? • How do they address it in terms of training?

43. The application process

44. How to get the spot… • Getting involved • Rotations • Applications • Making your list • Getting advice

45. Getting involved • Summer research projects • 3rd year clinical rotation • Interest group • PERSONAL CONTACT

46. Rotations • Usually do two different ones, at least one of which MUST be at a residency site. • Community vs. academic base • County vs. private • Rural vs. urban • Away rotations • Choose them early • Check schedule

47. Applications • The early bird gets the worm • Personal statements • Safe vs. clever • What are your weak spots? What are your strengths? • Building the resume with research, volunteer work, hobbies, etc.

48. Making your list • Getting information • SAEM Residency Catalog • EMRA Residency page • Grads from here • Location • Format • Program philosophy

49. Getting advice • Find a mentor with some experience in EM • EMIG advisors can help • SAEM virtual advisor • Outside rotation attending • Previous graduates • The interview trail – but be careful!

50. Interviews • It’s a search for psychopathology • Stress interviews are a thing of the past • Resident opinion counts • Secretary opinion counts