Advice From an Emergency Medicine Residency Director

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Session 107

Emergency medicine residency training requires lots of interpersonal skills. Dr. David Snow has been out of training for 6 years now. Today, he tells us more about the acuity, variety, and steep learning curve in EM.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:15] Interest in Emergency Medicine

Coming to the end of the third year in medical school, David was choosing between surgery, psychiatry, and emergency medicine. Ultimately, there were things about EM that appealed to him.

[Related episode: What is Emergency Medicine?]

[04:22] Traits that Lead to Become a Good EM Physician

When you get to a shift, it can get as busy as any other time during any other shifts in their life. They sometimes work at 5 am and 11 pm and it doesn’t matter what comes before that. They just have to be ready as they walk in the door. This is not unique to EM at all, but it is unique across all the fields of EM. As an EM doctor, you have to understand the unpredictable nature of the specialty. 

'We show up ready to work our hardest the moment we walk through the door.'Click To Tweet

Additionally, interpersonal skills are important as you could be speaking to patients from all walks of life.

Alongside, you’d also be networking with clerks, nurses, medical students, and division chairmen. You have to be able to work with the challenges of that environment and do so with a smile on your face.

David has been evaluating residency applications for 7 years now. A few years ago, they added a new piece to the application for emergency medicine called the Standardized Letter of Evaluation. In any of the rotations you do, you will have one of these letters written for you.

This is a movement away from the Letter of Recommendation that students ask from an EM physician. It compares you to applicants from the current cycle and the previous year. The letter also lists a set of attributes that talk about your success within those attributes as well as your work ethic, professionalism, etc.

There are also specific pretext parts to the document where people speak very candidly about the applicant. Emergency physicians are looking for the same things. They somewhat know what to write. 

[Related episode: Looking at Emergency Medicine Match Data and Surveys]

[10:50] Pass-Fail System Evaluating Students

David thinks there are so many facets to a pass-fail system. He believes it could be hard from the student’s standpoint as a sub-average USMLE Step 1 score can be very detrimental to an applicant.

Programs can use filters based on USMLE or COMLEX scores and that one score can be very hard for them to move past to ensure the reviewer doesn’t get stuck on that. There’s no recommendation an applicant needs to have taken Step 2. But if the Step 1 score is below the mean, it’s encouraged that they take Step 2 so they can work past that. This being said, it adds a lot of pressure to all of it.

[Related episode: What Step 1 Score or Level 1 Score Should I Try to Get?]

[13:40] How to Stand Out in Rotations

David recommends getting in touch with EM faculty and to start interacting with them as early as possible so they can start asking questions. Most medical schools that have EM departments have some way to get shadow shifts with EM faculty.

Nevertheless, he doesn’t think there should be pressure for students to get in front of PD during their second or third year. You just have to do what has to be done to figure out that EM is for you. If meeting with a program is the way to do that then fine. But don’t feel like you need to do that in order to bolster your application.

'Just take third year for what it is. It's a way to get exposure to all of these different fields of medicine and try to learn as much as you can.'Click To Tweet

Ultimately, just enjoy your rotations during third year as your learnings are all going to be very useful for your future training.

Donald underlines understanding the key attributes of an EM physician. They are hardworking. They don’t complain about the work before them. They try to enjoy as much as they can. It’s important to have that positive outlook and the desire to come in and take care of patients.

Be able to come in wiith those attributes without trying to be held back by your nerves. Understand you’re still a student and not a resident yet so your level of knowledge is obviously below the residents.

Donald notices how many students come in during rotations where they feel this need to prove they know what they’re doing. He advises students to step back from this. ED is challenging itself. Just find your team and enjoy your time.

'Understand that residents are underpaid and overworked. So anything you can do to remove a piece of work from a resident, they will love you forever.'Click To Tweet

Anything you can do to help out a resident would be golden. They would thank you and love you for that.

Try not to think about the importance of the rotation and just be yourself. Be that motivated and driven medical student on the rotation who’s there to learn and work. Being so focused on proving and performing would only limit yourself from feeling what it might be like to be that person in the field.

[24:55] The Biggest Misconceptions About Emergency Medicine

Many students are drawn into EM by trauma and acute resuscitation. Although this is a huge part of what they do, it’s far from being a true EM clinical life. It’s a big part but it’s not a huge part of an EM physician’s life.

'Try to understand what the day-to-day EM world is like.'Click To Tweet

Another misconception about Emergency Medicine is the idea of burnout. David believes that so much of this is born out of the habits formed during residency. You might do all of that right and end up in a job that makes you very unhappy but then you must change jobs because if you don’t, you’ll fit in that burnout spectrum.

David clarifies it’s not a false label as this is what’s being shown on the survey. But he doesn’t think this should preclude you or stop you from going into a career in emergency medicine.

'You just need to know what can happen to any physician if things are left unchecked.'Click To Tweet

[29:20] The Training Path

What differentiates EM from other programs is that by Day 1, you may have the sickest patients of your residency training.

In most programs, the system is set up to where you might not be going to an operating room or ICU during your first year. They would still build up your knowledge and experience before you’re exposed to that.

In emergency medicine, the learning curve is steep. It can be truly overwhelming in terms of the knowledge needed and every patient encounter you have for the first several months. But there will be an attending physician with them throughout the process.

'From Day 1, they're going to be exposed to patient care across the full spectrum of EM.'Click To Tweet

You will also be doing 5-7 off-service rotations during the first year. You will go to ICU’s and do orthopedics, anesthesia, and obstetrics.

On your second and third year, it will progress to increased patient care responsibilities. You will start to lead teams. There will be teaching and mentoring aspect to that.

When you get to your third year, you will start to lead the areas you’re working in. And when you’re done with your training, you need to be able to handle whatever comes through those doors at any point of the day.

'It's a lot. It's busy. It's exciting. But it's doable during those three years.'Click To Tweet

[32:33] How Students Can Evaluate What Programs They Can Apply To

David thinks the program has become so competitive that there’s no standardized way of mentoring an applicant as no two applicants are the same. That said, the applicants themselves don’t know where they stand on the bigger scale of applicants.

Because of the varying degrees of mentoring, students are picking up a lot of interview spots early when they probably don’t need to. Then they cancel a lot. So there’s a whole bigger issue here.

David recommends that students seek someone who has experience in reviewing applications. They can look at your file and compare you to other applicants to give you a clear sense of what’s important and where you might fall on that spectrum. This way, you can start thinking about how many applications you should be submitting.

Ultimately, David outlines two things to know if this is something for you. First is to get into EM if you really think that EM is right for you.

Second, experience at least two different types of EM programs. This could be an affiliate with the college of medicine. Or there could be close ties between the medical school and the ER department. There’s also a community program that doesn’t have a medical school in the area. There are also hybrid models that exist.

'I don't think an applicant should know what type of program they want. You've got time and you use your interviews to figure this piece out.'Click To Tweet

At the end of the day, see if the message of the chair is something you would put your faith in. Pay attention when they’re speaking. Then try to see if you like the residents and you fit in.

[39:30] Bias Against Osteopathic Students

David doesn’t think there is any negativity that needs to be overcome. He believes allopathic and osteopathic students are viewed in the same way. However, he feels there may be still some programs that will require a USMLE score.

Because of this, it could be hard for them to mentor an osteopathic student and tell them they need a USMLE score. He hopes there is some way to measure this going forward where programs are moving away from requiring USMLE scores.

[Related episode: 6 Myths of Osteopathic Medical School]

[42:45] Final Words of Wisdom

Don’t be afraid to reach out to people and residency leadership to ask for advice. They want to find people that can do the work that’s put before them. Most importantly, just be yourself and enjoy the time in the clinical setting. He assures you will get way more out of this.


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