Ways To Ace Residency

Image Credit: Pexels

Author: Adriana Coleska, MD, AAEM/RSA Board of Directors

Originally published: Common Sense

November/December 2019

My name is Adriana and I am one of the AAEM/RSA Board Members and your liaison to the Publications and Social Media Committee. As I transition into my role as the senior resident, I thought I would share with you a few tips that have helped me enjoy my time in residency and make the most out of the learning opportunities.

1. Save the numbers of all of your co-residents in your phone!
   Your co-residents are your lifeline. You should always be able to count on them for advice, shift swaps, check-ins, and that occasional “sorry I’m running late” text. You don’t want to be fumbling around looking for numbers in a time of need.
   
   

The Last Lecture to the Newly Graduating Emergency Medicine Residents

Author: James Keaney, MD MPH MAAEM FAAEM
First President of AAEM
Originally published: Common Sense May/June 2019

The Current Climate of EM – How Did We Get Here?
There are several recurrent phrases making their way into the vernacular of emergency medicine including transmutation, Joe the Plummer, the Leviathan Levy, and tumbleweed doctors.

The transmutation of clinically generated fees into management money is the theme of this talk revolving around the misallocation of Medicare-approved, clinically generated fees by practicing doctors into administrative wealth. The premise of the talk is this transmutation not only provides zero-point-zero real benefit to the physician, possibly even has negative effects, but also represents a public health detriment to the communities in which the hospitals are located.

Getting the Most Out of Residency

Image Credit: Pixabay

Author: Meaghan Mercer, DO
2014-2015 RSA President
Originally Published: Common Sense September/October 2014

As I enter my third year of residency, the end of training is becoming more of a reality every day. I have received many pearls of wisdom along my path from medical students to residents to soon-to-be-attendings. With less than a year to go, I remind myself every day that I should make the most of each day of my education — and I hope you will do the same. A huge thank you to the members of AAEM/RSA, who really have been with me all the way. Reflecting on these past few years, I want to share some advice that has helped me succeed.

Residency Work Hour Restrictions: Is the Pendulum Swinging Back?

Author: Mike Wilk, MD
PGY-1, Brown EM
Originally Published: Common Sense January/February 2017

“I walked into the hospital on my first day of residency and didn’t walk out until 36 hours later. Those were the darkest days of my life, but I am the doctor that I am today because I went through that,” I still distinctly remember these words from one of my more senior physician mentors when our discussion turned to work hour restrictions. As I wondered how it was possible to physically stay awake for so long, there was no doubt in his mind that work hour restrictions were dampening the training experience of newly minted residents.

First instituted in 2003 and revised again in 2011, interns now “enjoy” an 80-hour work week restriction with a maximum shift length of 16 hours (PGY-2s and above are still allowed to work up to 28 consecutive hours). However, the pendulum may be swinging back on strict work hour restrictions as new research on the topic becomes available.

The event that led to work hour restrictions was the death of Libby Zion in 1984. An overworked medical intern on a 36-hour shift prescribed meperidine to the 18-year-old patient, who was on an antidepressant, the MAO inhibitor phenelzine. This drug combination is thought to have caused the serotonin syndrome, leading to Zion's death.

How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 2

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO PA-C
Senior Emergency Medicine Resident, Thomas Jefferson University

Author: Andrew W. Phillips, MD Med
Critical Care Fellow, Stanford University, Division of Critical Care
Staff Emergency Physician, The Permanente Group

In “Improving Efficiency for Residents, Part 1” (Common Sense, Mar/Apr 2016), we discussed patients per hour (pt/hr), factors influencing efficiency, and the value of efficiency. In this article we will share advice on how to safely improve efficiency.

Recap of Part 1
Our review showed that PGY-1 residents average between 0.73 and 1.06 pt/hr, PGY-2 residents range from 0.85 to 1.33 pt/hr, and senior residents see between 1.05 and 1.41 pt/hr.1 These numbers may seem a little low, but they are averages across several studies that include different shift lengths and practice environments. Some of the factors that influence efficiency are shift length (longer shifts appear to reduce productivity) and distractions (emergency physicians are interrupted every 5.8 minutes and are required to unexpectedly switch tasks every 8.7 minutes).2,3

Speed versus Efficiency
Learning to be efficient is more important than learning to be fast, and there is a difference. The number of patients seen per hour, while important, does not tell the whole story. Avoiding discussions with patients, minimal documentation, and hurrying through procedures are not appropriate ways to increase patients per hour. Efficiency, however, makes use of all available resources to help move patients through the ED without cutting corners. It takes practice — lots of practice. As residents, we can all improve our efficiency.

How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 1

Image Credit: Flickr

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO, PA-C
Thomas Jefferson University

Author: Andrew W. Phillips, MD, Med
Stanford University, Division of Critical Care

Read part 2 here: Improving Efficiency for Residents


Residency is a time for improvement. Improving procedural skills, gaining clinical acumen, and growing knowledge are chief goals during residency. Efficiency is also a necessary skill for the budding emergency physician. After learning the core knowledge of emergency medicine and becoming competent in procedures, efficiency is the next item for residents to emphasize. How can efficiency be improved? How can residents tell if they’re moving too slowly or too quickly? How can a resident improve efficiency without missing important details or skimping on documentation? We will answer these questions in a two-part series. In this first article, we will review the average patient volume seen by residents, the concept of relative value units (RVUs), and touch on the idea of efficiency. In part two, in the next issue of Common Sense, we will discuss methods for improving efficiency based on expert recommendations and research.

Patients Per Hour
Residents often ask, “How many patients should I see per hour?” The answer is complicated. A resident’s patients per hour (pts/hr) rate depends upon many factors. Table 1 provides a general idea about the average number of pts/hr seen by residents. Several studies indicate that the pts/hr increases from intern year to senior year. However there is some overlap between each year of training. Across all included studies, interns (PGY1) averaged from 0.73 to 1.06 pts/hr; PGY2 residents ranged from 0.85 to 1.33; and senior (PGY3) residents ranged from 1.05 to 1.41.[1-8] Administrative and supervisory responsibilities also increased for senior residents, perhaps reducing the number of pts/hr for PGY3 residents to some degree.[3-4] As a comparison, two studies evaluated patients seen per hour by attendings. A retrospective study of 912 attending physicians at 61 EDs showed an overall average of 1.72 (SD=+/- 0.44) pts/hr, with physicians at higher volume (over 45,000 visits/year) EDs seeing 2.07 (SD=+/- 0.32) pts/hr.[9] Another study of attending physicians indicated an average of 1.87 pts/hr while working alone and 1.99 pts/hr while working with residents.[10] Bear in mind that this is at academic centers — by definition, since we’re discussing residents. Moreover, the numbers reflect not only physician speed but also patient demographics, such as whether or not pediatric patients are included or if there is a Fast Track that siphons away less complex patients – factors which are generalized in our summary.

6 Elements to Consider When Making Your Rank List

Image Credit: Flickr

Author: Matthew Camara
MSIV - Ross University
International Rep, AAEM/RSA Medical Student Council '14-'15

When interview season is underway, students have the task of putting prospective programs into a rank list. It may be beneficial to start creating a preliminary rank list based on information that is available to you for each program. As you complete your interviews you can move programs up or down until you’ve created your final rank list.

While these are not in any particular order, they are all things to consider while putting your rank list together.

1. Location
Many students have already considered geographical location when applying to residency programs, but as EM has become more competitive students are applying more broadly. When making your Match list it is still important to consider where you will be living for the next three to four years. Consider the climate, living expenses, things to do in the area, and how far away you are willing to be from family and friends. If you have a significant other, but are not going through the Couples Match, ranking in the same geographical location is something that may be more important to you than other candidates.

2. Three vs. Four Year Program
A major consideration when creating your rank list is whether you feel a three or four year program is right for you. Both have benefits as well as downsides. Three year programs offer a faster route to begin your own practice or fellowship. Whereas four year programs offer an additional year of mentored training that some feel make you more appealing to prospective employers. Three year programs also offer a financial advantage over a four year program, as you make an attending’s salary one year earlier. However, hospitals with a four year residency program may not hire a new graduate from three year program without an additional year of experience. Also, three year programs may be more congested with less elective time compared to a four year program. Some would suggest that the added time in a four year program allows you to explore possible niches within EM. Opinions on the ideal training length will continue to vary, but ultimately both models offer excellent training for EM physicians. What matters is that you find the right training model to fit you.

3. Community vs. University Program
Both community and university programs offer great training experiences. While both will prepare you for a successful career, each have unique differences. Community hospitals tend to have smaller residency programs with less total residents. Often there are plenty of procedures and hands on time with limited competition from residents in other specialties. Community programs also mirror the practice setting that a majority of graduates will go into after residency. On the other hand, university hospitals generally have a greater focus on research and academics. Often they have more resources at their disposal which allows them to practice medicine that is cutting edge. University hospitals also tend to be tertiary care centers where you can see a diverse patient population with complex pathology leading to unique experiences in off-service as well as ED rotations.

It is important to keep in mind that many programs blur the line between these two types of institutions. University programs have community ED rotations, and some community programs are affiliated with university centers. It ultimately comes down to researching the specific program to see what experiences they offer to their residents, and deciding what setting will be best for you.

Relevance of New CDC Opiate Guidelines for Emergency Physicians

Author: Samuel Bergin, MSIV, Uniformed Services University of the Health Sciences
Chad Roberts, MSII and Scott Pew, MPH Candidate
University of Utah
Originally Published: Modern Resident April/May 2016

Epidemiology
While the CDC was compiling data from 1999 to 2014, more than 165,000 people in the US died from overdoses linked to prescription opioids.[1] The opioids most commonly prescribed include methadone, oxycodone and hydrocodone. From 2004 to 2010, ED visits due to abuse of prescription drugs increased 115% while visits due to illicit drugs increased 18%.[2] Currently up to 1,000 people per day are treated in emergency departments for misusing prescription opioids. While emergency physicians are responsible for less than 5% of immediate and extended-release opiate prescriptions, they prescribe opiates for 17% of ED discharges.[4] Reasons for ED opioid prescriptions most commonly include back pain, abdominal pain and fractures/sprains.[4] We are in a position to help play a pivotal role in prescriptions, addictions and treating overdoses.[3]

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Patient Satisfaction

Common Sense - AAEM Member Magazine

Author: Victoria Weston, MD
AAEM/RSA Immediate Past President
Originally Published: Common Sense March/April 2016

Patient satisfaction. It feels like sometimes the concept is overemphasized, yet another addition to the countless expectations and constraints placed on doctors. I have felt this way at times, but recently my thinking has shifted. Instead of trying to meet arbitrary Press Ganey requirements, I have focused on trying to understand patients' wants and needs in order to better connect with them.

I recently had a shift with what seemed an unusually high number of patients with difficult personalities and “supratentorial pathology.”At times it was exceptionally frustrating, and although I started the shift feeling positive, by midway through the morning I could feel my spirits sinking. People had psychosomatic complaints. Some were drug-seeking and negotiating for narcotics. Some were demanding inappropriate care or tests. Some acted entitled and were rude to staff. I took this as a challenge, and tried to reframe my mind to see it as a learning experience in how to deal with difficult patients.

Age-Adjusted D-Dimer in the Evaluation of Venous Thromboembolic Disease

Common Sense - AAEM Member Magazine

Authors: Lee Grodin, MD; Raymond Beyda, MD; Kaycie Corburn, MD; Jacqueline Shibata, MD
Edited By: Jay Khadpe, MD FAAEM and Michael C. Bond, MD FAAEM
Originally Published: November/December 2016 Common Sense

The D-dimer test is an important and widespread tool to assess for venous thromboembolic disease (VTE) in low risk patients. The test has a high sensitivity and negative predictive value; however it is also prone to false positives. Additionally, as D-dimer levels naturally rise with age, the test may lead to more frequent false positives in the elderly than the general population. Recently several investigations examined age related refinements to the interpretation of D-dimer results to rule out VTE. For this month’s resident journal review, we review two retrospective studies and one prospective study that evaluate using age-adjusted D-dimer levels to increase its specificity while retaining its sensitivity. Verification of the results of studies could reduce the use of expensive imaging studies, reduce patient exposure to radiation and contrast, and prevent unnecessary hospital admissions and anticoagulation. These issues are particularly pertinent for the elderly population.

Physician Advocacy: Disability Coverage for the EP

Photo Credit: Flickr - Zeevveez

Author: Linda Sanders, MD
Temple University Hospital
Originally Published: Modern Resident February-March 2016

As a new generation of residents prepares to enter private and academic practice as attending emergency physicians, most intend to practice emergency medicine for the next 30 years, maybe more. But in an environment that demands that we have fine motor skills, quick decision making abilities, fast communication and the ability to practice at least eight hours a day, a physical or mental ailment can make one incapable of EM practice. The incidence of disability among practicing physicians is around 2-10%.[2]

Tox Talks: Lithium Toxicity

Author: Kaitlin Fries, DO PGY1
Doctors Hospital
Originally Published: Modern Resident, December 2015/ January 2016

Lithium is often a first line treatment for bipolar disorder and major depressive disorder, and is commonly present on many emergency department patients’ medication lists. Studies have shown that as many as 75-90% of patients taking lithium long-term develop toxicity at some point throughout their treatment.[5] This is primarily due to the fact that lithium has a very narrow therapeutic index. In 2008, the American Association of Poison Control Centers received over 6,000 reports of potential lithium toxicities and four reported deaths.[5] While lithium toxicity is not as commonly seen as some other toxidromes in the emergency department, it is still very relevant to daily practice.

Journal Club: Steroids for Everything?

Author: Linda Sanders, MD PGY3
Temple University Hospital
Originally Published: Modern Resident, December 2015/ January 2016

Back Pain
A randomized controlled trial (RCT) in which 269 patients with lumbar radiculopathy on MRI and low back pain were given a 15-day course of prednisone versus placebo demonstrated an improved disability score at three weeks after receiving steroids.[3] By comparison, a RCT of 67 patients presenting to the ED with musculoskeletal pain from a twisting or bending injury not thought to be radicular in nature demonstrated no benefit in pain or disability with prednisone at one week.[2] Thus, steroids may benefit patients with lumbar radiculopathy but have no demonstrated benefit in those with musculoskeletal back pain.

Pharyngitis
A Cochrane review of eight RCTs comparing steroids to placebo demonstrated that patients given oral or intramuscular steroids for pharyngitis were three times more likely to have resolution of pain within 24 hours with a number needed to treat of 3.7.[4] Most trials used a single dose of dexamethasone and all eight studies gave both groups antibiotics. Thus there is no data demonstrating the benefit of steroids without antibiotics.

TXA Literature Review

Author: Alexandra Murray, DO PGY1
Mercy St. Vincent Medical Center Emergency Medicine

Originally Published: Modern Resident - December-January 2016

What is tranexamic acid (TXA)?
When the body experiences vascular injury, the hemostatic system tries to maintain circulation by balancing the formation and degradation of blood clots. In response to severe blood loss, this balance is challenged and hyper-fibrinolysis can occur. The conversion of plasminogen to plasmin plays a large role in fibrin binding and degradation. Tranexamic acid is a synthetic derivative of lysine that reversibly blocks binding sites on plasminogen and inhibits fibrinolysis.[1] TXA has been approved by the FDA since 1986 as an antifibrinolytic and has been marketed for menorrhagia (Lysteda) and dental hemorrhage in hemophiliacs (Cyklokapron).[2,3] More recently, TXA has been investigated as a treatment for posttraumatic hemorrhage, postpartum hemorrhage and prevention of surgical blood loss.

Acute Aortic Syndrome

Photo Credit: Charlotte Astrid

Author: Nathan Haas, MD PGY-1
University of Michigan

Originally Published: Modern Resident, February/March 2015

The acute onset of severe, ripping chest pain radiating to the back quickly brings to mind the diagnosis of aortic dissection. However, dissection is just one potential etiology of Acute Aortic Syndrome (AAS) which includes the acute presentation of aortic dissection, penetrating atherosclerotic ulcer, intramural hematoma, aneurismal leak and traumatic transection. Overlap frequently exists between these processes, and the various etiologies within AAS in some ways represent more of a spectrum of disease than distinct entities.

Aortic dissection results from an intimal tear penetrating the aortic media, with progressive dissection of the media creating a false lumen. Contrarily, a penetrating atherosclerotic ulcer occurs at the site of a preexisting atherosclerotic plaque and is the result of intimal erosion through to the media. Intramural hematoma is defined as a blood collection in the media without the presence of an intimal flap and physiologically is driven by the rupture of vasa vasorum. Aneurismal leaks are related to the acute expansion of a preexisting aortic aneurism. Traumatic transection most frequently occurs secondary to a rapid deceleration injury and classically occurs immediately distal to the left subclavian artery at the ligamentum arteriosum.

Be a Non-Terrible Intern in Ten Easy Steps

Image Credit: ReSurge International

Author: Gregory Wanner, DO PA-C

Thomas Jefferson University Hospital

Welcome to residency! Now that you’ve had some time to learn the hospital computer system, find the coffee maker, and begin to settle into your new role as an intern, it’s time for a few tips. Intern year is tough. You have a whole new set of responsibilities, and for some this is your first “real” job. There are many ways to be a terrible intern, but you can avoid terribleness and become a wonderful intern.

Over my ten years in medicine, initially as a physician assistant and now as a senior resident, I’ve had quite a bit of exposure to interns. Plus, I was one not so long ago. As interns we all have times — often brief — when we feel brilliant, as well as times we feel completely incompetent. We have moments of enlightenment and moments when we need to be bailed out by nurses or attendings. This is to be expected. The goal is to learn from your mistakes and eventually become a great physician. To learn what you can do to further your own education, keep your attendings relatively happy, and avoid terribleness: read on.

Peds Tox Talk: Liquid Nicotine

Photo by Lindsay Fox

Author: Ashley Grigsby, DO PGY-1
Indiana University Emergency Medicine/Pediatrics

Originally Published: Modern Resident, June/July 2015 

Nicotine toxicity is a well-described clinical entity that often occurs in children who accidentally ingest cigarette buds or nicotine patches. However, a new form of nicotine has the potential to cause serious clinical symptoms, including death.

E-cigarettes use a form of liquid nicotine of varying concentrations that come in individual vials. E-cigarette use is on the rise across the United States, and unfortunately, the liquid nicotine is both easily accessible and appealing to young children. These liquid cartridges are often packaged in a tempting way, with one such cartridge described as having a cartoon monkey holding grapes on the front. The packaging is not regulated by the FDA and therefore has no child proof regulations for packaging. The liquid itself is also appealing for young children, and flavors include cotton candy, bubble gum, fruit, mint and chocolate.[1,2]

The CDC reported a significant increase from 2010 to 2014 of calls to poison centers regarding nicotine exposure. They also reported that e-cigarette exposure compared to regular cigarette exposure was about 1.5 times more likely to cause an adverse health effect.[1] Among the calls to poison centers during this time period, 51% involved young children.[2]

Resident Rules of the Road: Chapter 11 Summary: "Wellness"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010. http://www.aaem.org/publications/aaem-book-store

Chapter Summary Edited By: Andrew W Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program  

Summary Series Editors: Muhammad Alghanem, BS and Andrew W Phillips, MD MEd

Physician—heal thyself.

It is difficult to estimate exactly the burnout rate in emergency medicine (EM) since it is a relatively young specialty, but there is no denying that it is a stressful specialty prone to burnout. Here, we provide some tips for preventing burnout.

Shift Work/Sleep
Dealing with night shifts: If you move to a regular night schedule, keep that schedule even on days off whenever possible to keep your circadian rhythm. Be cautious that day sleepers often do not get as good of sleep as night sleepers and will lean toward using stimulants and sedatives. Scattered, single night shifts may be preferable. A third alternative is a forward-moving schedule: day to evening to night to break. Shorter shifts (8hr) and 30-45 minute power naps before night shifts are helpful to remain alert. Experts also recommend sleeping as soon as possible after a night shift.

Resident Rules of the Road: Chapter 10 Summary: "The First Year Out"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010. http://www.aaem.org/publications/aaem-book-store.

Chapter Summary Edited By: Andrew W Phillips, MD MEd, Stanford/Kaiser Emergency Medicine Residency Program

Summary Series Editors: Muhammad Alghanem, BS and Andrew W Phillips, MD MEd

There’s a light! Do you see it? The end of the tunnel! Except … wait — it’s fading as you realize that now your name is at the bottom of the chart, that utopic emergency department staff doesn’t actually exist, you still have disrespectful consultants, the boards are approaching, and Press Ganey now applies to YOU!

Never fear — your AAEM and AAEM/RSA colleagues are here, just as they always have been!

Resident Rules of the Road: Chapter 9 Summary: "Job Search"

Originally Published: AAEM's Rules of the Road for Emergency Medicine Residents, 7th Ed. Chief Editors: Tom Scaletta, MD FAAEM; Michael Ybarra, MD FAAEM; Leana Wen, MD MSc. AAEM and AAEM/RSA. Milwaukee, WI. 2010.

http://www.aaem.org/publications/aaem-book-store.


Chapter Summary By: Aga De Castro, MPH, MA, MSIV Medical Student, Georgetown University School of Medicine


Summary Series Editors: Muhammad Alghanem, BS, and Andrew W Phillips, MD, MEd


Finding employment after residency can be a stressful period but maintaining an organized yet flexible approach can lead to finding that first job as an independent emergency physician. A few things to consider when going on the job hunt:

1. State licensures can often take months to process. Starting up to a year ahead of your desired start date will allow you appropriate time.
2. Know your priorities. Do you have a geographic area in mind? Or are you looking for opportunities only in academic centers?
3. Finding a job is easy but finding the perfect job requires more time and effort. Invest the energy if you want your job out of residency to be the most ideal.
4. Know your network. Often, the best job opportunities are not advertised and only known through the grapevine. People associated with your residency program such as the leadership and alumni can be helpful contacts for potential job opportunities.