Residency Training Overkill

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EMNation

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Hey everyone,

Just curious what everyone else's perspective is on this? What I am basically asking is - do you think there is such a thing as being overly prepared (especially in our field)? I.e. my thought process for picking a residency destination was that I want a high volume (patients per resident), level 1 trauma center with enough (but not nonstop) trauma, that would make me more than capable when I left to do a solid job. This definitely factored into my final rank list as some programs that I felt had weaker training were lower, while those who arguably had extra intense (almost unnecessarily) training were also lower.

I spoke to a Kaiser ER doc recently and she said: "80-90% of you coming out will work at a place like this, where it is so rare that trauma is anything too bad, and you've seen way more than enough that you know what to do. The other 10-15% at big county scary academic centers will be giving their senior residents the lead and having their junior residents doing procedures. And as far as multi tasking, having gone through residency you will be more than fine doing it."

Thoughts?

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no such thing as overtraining. the only area where it may be more then you need, would be trauma. its a scary world out on your own and you want to see as much as you can.

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Hey everyone,

Just curious what everyone else's perspective is on this? What I am basically asking is - do you think there is such a thing as being overly prepared (especially in our field)? I.e. my thought process for picking a residency destination was that I want a high volume (patients per resident), level 1 trauma center with enough (but not nonstop) trauma, that would make me more than capable when I left to do a solid job. This definitely factored into my final rank list as some programs that I felt had weaker training were lower, while those who arguably had extra intense (almost unnecessarily) training were also lower.

I spoke to a Kaiser ER doc recently and she said: "80-90% of you coming out will work at a place like this, where it is so rare that trauma is anything too bad, and you've seen way more than enough that you know what to do. The other 10-15% at big county scary academic centers will be giving their senior residents the lead and having their junior residents doing procedures. And as far as multi tasking, having gone through residency you will be more than fine doing it."

Thoughts?

There's a reason people on this forum say that every ACGME approved residency program will train you to be an adequate EP.
 
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The establishment has an official opinion that balances your training with the manpower needs related to moving meat at your particular facility and fulfilling agreements with offservice specialties to accomplish scut. This official opinion is hallowed by years of tradition and is considered inviolable by the powers that be. Go back to sleep. In the first two to three years post residency working at a busy community level 2 or 3 community shop you will see what EM is really all about.
 
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I like getting the S@&$ beat out of me on trauma shifts. It lessens the ability of anything else to stress me out.
 
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If you can't deal with the cortisol release that accompanies having 2-3 sick patients or 6-8 not obviously sick patients dumped on you at once then you probably should have trained harder. It's entirely possible to see 2 pts/hr and still be significantly behind the curve compared to your peers if you never develop the ability to handle surges. With that being said, every program should be able to provide that experience to a motivated resident.
 
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This is kinda the same argument regarding 3 year vs 4 year residency training sites. Is the 4th year overkill? Well, if you ask most of the people who graduate from an EM residency the answer is yes. If you ask the guys who did the 4th year, some say yes and some say no. It's all in the eye of the beholder.

Also, trauma is great and all, but it's not the end all be all. She is spot on to say that most sites don't get that much level 1 trauma and most of the time our role in it is somewhat limited. You won't find people doing clamshell's or REBOA in the community.
 
Residency training overkill?

Fat chance. EM is tough work. Anything can come through the door. Three grueling years of residency is a requirement to even begin to deal with what you will as an attending.
 
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Imo most docs will say you still have a ton to learn even after you get out (that doesn't mean you have to do the half price attending year aka 4 year residency, however). There's no such thing as overtraining, that's pretty hilarious.
 
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I think it depends on what you mean by "overkill." You can never see "too many" patients in residency. At the same time, I don't think you need to be at a place where residents do 100000 procedures. Once you've done your 100th intubation you'll get more out of seeing the fussy 5 wk old who looks borderline rather than doing another tube.
 
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I've never heard a new attending say, "I'm too prepared for this job."
 
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I think it depends on what you mean by "overkill." You can never see "too many" patients in residency. At the same time, I don't think you need to be at a place where residents do 100000 procedures. Once you've done your 100th intubation you'll get more out of seeing the fussy 5 wk old who looks borderline rather than doing another tube.
I think this is under appreciated. Everyone comes out of residency knowing how to resuscitate and knowing what to order for a workup. The hardest part of the job after residency is actually knowing who not to work up.
 
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Unless you're working 80 hours per week and seeing 4 PPH then I wouldn't call it overkill.

Trust me, US residents have it easy compared to some countries.
 
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[QUOTE="alpinism, post: 17640868, member: 432776]

Trust me, US residents have it easy compared to some countries. [/
QUOTE]

Really? I feel our American residency training is way more rigorous than most other countries including European ones that are 9-5 sort of mentality.
 
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Unless you're working 80 hours per week and seeing 4 PPH then I wouldn't call it overkill.

Trust me, US residents have it easy compared to some countries.
.
Yes and no. We get out in 3 to 4 years, after 3-4 years of medical school.
Most other countries do a 6 year MBBS model and then go into 5-7 years of purgatorial training. But they don't see patients during med school, and don't write notes. Residency training is not at one site, and basically they act as apprentices instead of getting direct teaching from attendings 24/7 like here. The plus side, if you're a consultant, is you don't work nights and weekends. The downside is they learn at a much slower and self directed rate. In the end, they pass the tests, but I'm not sure we can directly compare the training.
Yes, there are some slaughterhouses out there, but they're not the norm.
 
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Maybe 10 years ago...

At least in my experience, all the British, German, Austrian, Japanese, and South Africans I've worked with saw patients as med students.

As of this year many European med students (5 year MBChB or 6 year MBBS) spend at least 2 years doing "placements" and "electives" similar to US rotations. During both years med students see patients under supervision. While they have little to no responsibility for actual patient care, neither do most US med students nowadays.

But on the whole, yes, nearly all European registrars work less hours compared to US residents. In any event, some countries do have particularly brutal training schedules compared to the US. In South Africa at the moment EM registrars commonly work 60 to 80 hours per week including 16 to 24 hour shifts in the ER.
 
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Hey everyone,

Just curious what everyone else's perspective is on this? What I am basically asking is - do you think there is such a thing as being overly prepared (especially in our field)? I

Yes, I think a four year residency is "overpreparation." Obviously, others feel differently or those residencies wouldn't exist.
 
At some point, no matter how long you're in training, you reach a peak of what you can learn without truly being independent. It's like learning to ride a bike. At some point, keeping the training wheels on no longer helps, in fact they're holding you back. At some point, you've got to spread your wins and fly, baby.
 
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Agree with Birdstrike. Once you're on your own you'll learn a lot more - but no matter how long you spend in residency you won't learn those things. So you're not technically overtrained, but you may reach a saturation point of 'residency learning'
 
Agree with Birdstrike. Once you're on your own you'll learn a lot more - but no matter how long you spend in residency you won't learn those things. So you're not technically overtrained, but you may reach a saturation point of 'residency learning'
It doesn't have to be that way but it would require a major shift in the emphasis of the last year of residency. Things like managing ED flow, efficient use of testing, ending difficult patient encounters in a reasonable manner could all be taught but it would require more clinical time the last year of residency as they just aren't skills that residents can prioritize while trying to learn the basics of resuscitation and work-up.
 
As a 4th year resident approaching graduation, this 4th year of training absolutely feels like overkill. Having said that, 3 or 4 years I just think there are some things I'm going to have to learn on the fly as a new attending. I think the last 6 months or so have been pretty low yield for me as a resident.
 
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At some point, no matter how long you're in training, you reach a peak of what you can learn without truly being independent. It's like learning to ride a bike. At some point, keeping the training wheels on no longer helps, in fact they're holding you back. At some point, you've got to spread your wins and fly, baby.

Go forth and spread your wins birdstrike
 
Go forth and spread your wins birdstrike
I'm gonna spread the wins so much, and you'll win, win, win, so much that you'll start telling me, "Birdstrike, I'm tired of winning. Can we stop, now?"
 
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I'm gonna spread the wins so much, and you'll win, win, win, so much that you'll start telling me, "Birdstrike, I'm tired of winning. Can we stop, now?"

make.php
 
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Hey everyone,

Just curious what everyone else's perspective is on this? What I am basically asking is - do you think there is such a thing as being overly prepared (especially in our field)? I.e. my thought process for picking a residency destination was that I want a high volume (patients per resident), level 1 trauma center with enough (but not nonstop) trauma, that would make me more than capable when I left to do a solid job. This definitely factored into my final rank list as some programs that I felt had weaker training were lower, while those who arguably had extra intense (almost unnecessarily) training were also lower.

I spoke to a Kaiser ER doc recently and she said: "80-90% of you coming out will work at a place like this, where it is so rare that trauma is anything too bad, and you've seen way more than enough that you know what to do. The other 10-15% at big county scary academic centers will be giving their senior residents the lead and having their junior residents doing procedures. And as far as multi tasking, having gone through residency you will be more than fine doing it."

Thoughts?

Residency is an overkill? Problem in some aspects. I mean trauma is cookbook. Now adays, just scan everything. That is what the trauma surgeons do.

I picked a trauma center, one of the busiest in the country. Wait time was 12+ hrs, busy, your tired. But when would I ever experience such volume or rare cases? Not in my current community hospital.

I am glad I saw everything in residency and nothing phased me when I was done. I literally was one of the fastest doc a week into my job.
 
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As a resident still in training, I would say no, there is no such thing as training overkill. The breadth of Emergency Medicine is staggering and to say that any residency will train you to comfortably take care of it all right out of the gate is lunacy. If you can't recognize this fact then you probably just haven't seen enough at your shop, or they just don't expect enough out of you at yours. But I also believe that we should do more than just stabilize and dispo.

Every residency has its strengths and weaknesses and you need to realize that when you pick your first job out of residency. All 3 year residencies should train competent EPs. As far as 4 year programs are concerned, after 4 years at the same training site, even the most hardcore county shops, you will get to know your population well, but once you go to a new shop with different pathology and different presentations, suddenly everything will start to feel foreign. That extra 4th year can be a boon if it is utilized efficiently to shore up weaknesses, do research, and really get a feel for being an attending. Even if you're at a shop where the attending lets you do whatever you want as s 4th year, it's still VASTLY different that first year out when it's your license on the line and you have no one to talk over the case with.

The atypical presentation of common disease or any presentation of rare disease can burn anyone. Just my 2 cents.
 
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As a resident still in training, I would say no, there is no such thing as training overkill. The breadth of Emergency Medicine is staggering and to say that any residency will train you to comfortably take care of it all right out of the gate is lunacy. If you can't recognize this fact then you probably just haven't seen enough at your shop, or they just don't expect enough out of you at yours. But I also believe that we should do more than just stabilize and dispo.

Every residency has its strengths and weaknesses and you need to realize that when you pick your first job out of residency. All 3 year residencies should train competent EPs. As far as 4 year programs are concerned, after 4 years at the same training site, even the most hardcore county shops, you will get to know your population well, but once you go to a new shop with different pathology and different presentations, suddenly everything will start to feel foreign. That extra 4th year can be a boon if it is utilized efficiently to shore up weaknesses, do research, and really get a feel for being an attending. Even if you're at a shop where the attending lets you do whatever you want as s 4th year, it's still VASTLY different that first year out when it's your license on the line and you have no one to talk over the case with.

The atypical presentation of common disease or any presentation of rare disease can burn anyone. Just my 2 cents.

I don't know man. I'm about to graduate and have been moonlighting for about a year. I feel comfortable practicing in the community. Don't get me wrong, I know there is a limit to my scope, but I feel ready to be on my own entirely.

Also, the more moonlighting I've done, the more I disagree with the statement that we need to do more than stabilize and dispo. I used to feel this way, but it's just not what we do. Twenty people in the waiting room in a community shop = get them out ASAP. Dying --> put them in the unit now. Walking wounded --> home now, call your doc tomorrow. In between, get what you absolutely have to in order to admit them and page the admitting doc.
 
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Not sure there is overkill, just more opportunities to see nasty **** that isn't reflected on you directly. IV pacers, maybe one or two more, ED thoracotomy, maybe one more... Community practice is far more hardcore than any training would suggest. We see conditions that would inflame, incite mass hysteria and activation of mass resources at higher level hospitals, but we just handle it. We don't have a choice, and we can't defer. When you have no backup, you need to act, there is no bull****, no "attending" bias - you make the decisions. I've worked level 1 to the level 4 I work in now, and the constant is we make the decisions at the point of care.

Another year of training wouldn't have helped - less support during training may have! But I feel well trained, and the crap that roils in is dealt with accordingly.
 
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Just get through residency. Just get through it. Then get a job. Work. Make money. Residency is just residency. You'll look back and think, "Wow, what a goat rodeo that was. Had some ups, downs, good times, bad times. Glad its over. Time to make some money."
 
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Just get through residency. Just get through it. Then get a job. Work. Make money. Residency is just residency. You'll look back and think, "Wow, what a goat rodeo that was. Had some ups, downs, good times, bad times. Glad its over. Time to make some money."

Goat Rodeo????
 
Goat rodeos are never good. Although they are entertaining to watch.
 
Goat rodeos are the only rodeos I will attend
 
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Hey everyone,

I spoke to a Kaiser ER doc recently and she said: "80-90% of you coming out will work at a place like this, where it is so rare that trauma is anything too bad, and you've seen way more than enough that you know what to do. The other 10-15% at big county scary academic centers will be giving their senior residents the lead and having their junior residents doing procedures. And as far as multi tasking, having gone through residency you will be more than fine doing it."

Thoughts?

Your first problem: You spoke to a Kaiser ER doc. They're well paid and... that's about it. Boring!! Look, you don't know what you're going to want to do or what you're going to end up doing. Maybe you'll be a ho-hum community doc churning out belly pains and sore throats somewhere. Maybe you'll be a gritty county doc throwing in chest tubes in hallways. Maybe you'll be an expedition doctor evacuating patients in Antarctica. Maybe you'll ditch the US for a while and go volunteer in Haiti, or work in New Zealand, or decide to do aeromedical retrieval in Australia, or join a rescue group and go to disasters. Who knows?? Go to the best program that fits your personality and has well-rounded training. When I was applying I tried to pick the most hard-core County program that also had good off-service and critical care rotations and at least a few months where I could do international electives. Physicians who end up practicing EM in other countries have a much wider scope of practice than we do - in the UK, Australia, NZ, etc., may spend months and months working as junior anesthetists and surgeons (post-internship but pre-residency, they call them "medical officers") before they specialize in EM. Do you need those skills? As an EM doc, being versatile and having the broadest scope of experience is, in my mind, the whole POINT.

Ask yourself this: Why are you going into EM? Is it to do a quick 3-year residency, land a nice community gig for 300K+ and move to the suburbs? Then yeah, just train anywhere. Is it because you want to see the world, work in a variety of practices, respond to disasters, CHALLENGE yourself? Then go find then most hardcore program and work hard.
 
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Your first problem: You spoke to a Kaiser ER doc. They're well paid and... that's about it. Boring!! Look, you don't know what you're going to want to do or what you're going to end up doing. Maybe you'll be a ho-hum community doc churning out belly pains and sore throats somewhere. Maybe you'll be a gritty county doc throwing in chest tubes in hallways. Maybe you'll be an expedition doctor evacuating patients in Antarctica. Maybe you'll ditch the US for a while and go volunteer in Haiti, or work in New Zealand, or decide to do aeromedical retrieval in Australia, or join a rescue group and go to disasters. Who knows?? Go to the best program that fits your personality and has well-rounded training. When I was applying I tried to pick the most hard-core County program that also had good off-service and critical care rotations and at least a few months where I could do international electives. Physicians who end up practicing EM in other countries have a much wider scope of practice than we do - in the UK, Australia, NZ, etc., may spend months and months working as junior anesthetists and surgeons (post-internship but pre-residency, they call them "medical officers") before they specialize in EM. Do you need those skills? As an EM doc, being versatile and having the broadest scope of experience is, in my mind, the whole POINT.

Ask yourself this: Why are you going into EM? Is it to do a quick 3-year residency, land a nice community gig for 300K+ and move to the suburbs? Then yeah, just train anywhere. Is it because you want to see the world, work in a variety of practices, respond to disasters, CHALLENGE yourself? Then go find then most hardcore program and work hard.


Someone drank the koolaid.
 
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Someone drank the koolaid.

Honestly, no. I'm in my fourth year out post-residency and this is how I live my life. We don't all need to hunker down in dystopian suburbia :).
 
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This is kinda the same argument regarding 3 year vs 4 year residency training sites. Is the 4th year overkill? Well, if you ask most of the people who graduate from an EM residency the answer is yes. If you ask the guys who did the 4th year, some say yes and some say no. It's all in the eye of the beholder.

Also, trauma is great and all, but it's not the end all be all. She is spot on to say that most sites don't get that much level 1 trauma and most of the time our role in it is somewhat limited. You won't find people doing clamshell's or REBOA in the community.


I disagree with the idea that a "Level 1" trauma center is great education for the ED doc. Those places are level 1 because they have a structure for dealing with the bad traumas, and it usually involves some sort of trauma team coming down and taking over.

A community ER program where the ED handles the trauma entirely is more valuable during residency than being designated to "the airway"

Also, we clamshelled a guy earlier in the year......and he made a full functional recovery. We don't do them a ton, but they do get done.
 
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Not sure there is overkill, just more opportunities to see nasty **** that isn't reflected on you directly. IV pacers, maybe one or two more, ED thoracotomy, maybe one more... Community practice is far more hardcore than any training would suggest. We see conditions that would inflame, incite mass hysteria and activation of mass resources at higher level hospitals, but we just handle it. We don't have a choice, and we can't defer. When you have no backup, you need to act, there is no bull****, no "attending" bias - you make the decisions. I've worked level 1 to the level 4 I work in now, and the constant is we make the decisions at the point of care.

Another year of training wouldn't have helped - less support during training may have! But I feel well trained, and the crap that roils in is dealt with accordingly.


Well said.

You rise the occasion if you have to
 
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As a resident still in training, I would say no, there is no such thing as training overkill. The breadth of Emergency Medicine is staggering and to say that any residency will train you to comfortably take care of it all right out of the gate is lunacy. If you can't recognize this fact then you probably just haven't seen enough at your shop, or they just don't expect enough out of you at yours. But I also believe that we should do more than just stabilize and dispo.

Every residency has its strengths and weaknesses and you need to realize that when you pick your first job out of residency. All 3 year residencies should train competent EPs. As far as 4 year programs are concerned, after 4 years at the same training site, even the most hardcore county shops, you will get to know your population well, but once you go to a new shop with different pathology and different presentations, suddenly everything will start to feel foreign. That extra 4th year can be a boon if it is utilized efficiently to shore up weaknesses, do research, and really get a feel for being an attending. Even if you're at a shop where the attending lets you do whatever you want as s 4th year, it's still VASTLY different that first year out when it's your license on the line and you have no one to talk over the case with.

The atypical presentation of common disease or any presentation of rare disease can burn anyone. Just my 2 cents.


What the hell does research have to do with being a better doctor?
 
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