Careers in Emergency Medicine PowerPoint Presentation

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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 Is EM right for you? How do I choose the right residency? 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 it’s needed VARIETY!!!

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Variety – the good part You 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.” “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”

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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 MD’s 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 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

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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 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!

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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 “you’ve 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 can’t 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 “I’m 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 don’t 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 isn’t 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 doesn’t 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 program’s 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… Getting involved Rotations Applications Making your list 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 It’s 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 don’t. 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@msnotes.wustl.edu 314-362-7983