Careers in Emergency Medicine

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Careers in Emergency Medicine

• Eric D. Katz, MD
• Assistant Director
• EM Residency Program
• Washington University in St. Louis

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54 male with chest pain and SOB

• Who do you call/see?
• Cardiologist
• Emergency Physician
• Internist
• Family Practitioner

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9 year old who fell down

• Who do you call/see?
• Pediatrician
• Family Practitioner
• Emergency Physician
• Neurologist

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19 female feeling depressed

• Who do you call/see?
• Emergency Physician
• Psychiatrist
• Internist
• Pediatrician

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I will not sell you a bill of goods

• The right field for you is only determined by you!

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3 Major Topics

1. Is EM right for you?
2. How do I choose the right residency?
3. How do I get the residency to choose me?

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What is EM all about?

• Stabilization
• Initial Diagnosis
• Initial Disposition
• Team work
• Patient care when its needed
• VARIETY!!!

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Variety the good partYou never know what is
coming through the door next.
Pathology vs. Bread and butter Surgical vs.
medical Pediatric vs. geriatric
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Variety the bad part

• You never know what is coming through the door
  next.
• Chest pain
• Psychiatry
• OB/Gyn days

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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.

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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

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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

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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

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Follow the Money

• 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

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Who goes into EM?

• I loved every rotation but felt too limited by
  every field until my EM rotation.
• Ive 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 dont want to be tied to a practice.
• I have lots of other interests

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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

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The Big Myth

• Burnout in EM is as high as 15 per year
• The truth
• EM BOARDED MDs have the same burnout rate as
  every other specialty. 5 per year (EM, IM,
  Peds, Surgery)

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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.

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Myth 3

• You can do another residency and moonlight in an
  ED if you want to
• Boarded EPs 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

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Emergency Medicine Residency
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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?

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How difficulty is it to get into EM?

• 1747 applicants for 1242 spots last year
• 7 programs didnt fill in last years match (13
  spots)
• International medical graduates
• Osteopaths
• Prior Training
• Previously failed to match
• Bottom line it isnt as bad as it seems!

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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.

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Residents

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

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EM Faculty

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

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Institution

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

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Support of Emergency Medicine

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

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Trauma

• Volume?
• Type?
• Organization?
• Competence?

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Pediatric EM

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

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Other Staff

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

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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

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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

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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

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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?

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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
• youve waited a long time already

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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 cant be faculty at 4 year program
• what do you bring to the institution?

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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
• Im not sure what I want to do!

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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

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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 dont have a
  certification pathway
• Do you need to do a formal fellowship?
• Unlike medical specialties limited financial
  benefit

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4-Year Format

• Financial idiocy for hospital
• 65000/senior in PGY4 year
• Resident lost wages
• Loan repayments loom
• Moonlighting isnt the same
• If really academically geared
• 3 years fellowship is more efficient

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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
  doesnt evaluate real-time clinical interaction

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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 programs specific mission statement?
• How do they address it in terms of training?

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The application process
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How to get the spot

1. Getting involved
2. Rotations
3. Applications
4. Making your list
5. Getting advice

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Getting involved

• Summer research projects
• 3rd year clinical rotation
• Interest group
• PERSONAL CONTACT

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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

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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.

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Making your list

• Getting information
• SAEM Residency Catalog
• EMRA Residency page
• Grads from here
• Location
• Format
• Program philosophy

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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!

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Interviews

• Its a search for psychopathology
• Stress interviews are a thing of the past
• Resident opinion counts
• Secretary opinion counts

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Playing the Game

• Just dont.
• Illegal questions deserve illegal answers
• 94 of US grads going into EM match in their top
  3.

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Its all about family and friends
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Summary

• This is a good gig if it is right for you.
• Residency is achievable and reasonable.
• When in doubt, go for your best fit.

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Thank you for your time!
Eric D. Katz, MD Assistant Professor Assistant
Director, EM Residency Program Washington
University in St. Louis Katze_at_msnotes.wustl.edu 31
4-362-7983