Finished up my week in the ER yesterday with the best day of the week. It started slow like the rest of the week, but about 10 am we had four ambulances arrive with fifteen minutes. We had some interesting cases like a 14 year old gymnast that had fractured her back and a guy that almost cut the tip of his finger off. I was able to suture the latter back together after injecting a bunch of anesthetic (big hands).
The best part though, was talking to a couple of the ER Docs I hadn't worked with until yesterday. I learned some very interesting things about ER and medicine in general. First, ER Docs typically make what they can bill the hospital for. So a Doc serving a poor population is going to make far less than a Doc serving a fully insured population - like half as much! So ER is in a very good position to benefit from any national health care plan. Even $20 or $30 per patient is better than the $0 they get today from those patients.
On a more scary note, a few ER Docs that have made a killing in the past by "owning" the hospital contracts with busy trauma hospitals. They then created partnerships and locked out any other Docs. By selling ownership into partnerships or just hiring ER Docs on salary and skimming off the top, a few made millions at the expense of their fellow EM Docs! Sounds like EM Residents need to watch out for secretive and closed book partnerships - especially in this age of mega-partnerships of EM Docs.
One of the two Docs finished his EM Residency then decided to do an Anesthesia Residency. After practicing a couple of years, he decided the overnight call every third night or so and poor lifestyle were too much of a sacrifice and went back to working ER! That was eye opening.
The other Doc works pseudo-Locum Tenens: he works odd shifts at four of five hospitals in a couple of Midwest states. His advice was that EM is great because it still allows you to do so different things. Not only do you have a controllable lifestyle, you aren't trapped (as I had assumed) into being a hospital ER employee for ever. Like a lot of creative Family Docs are doing, you can open a "wellness center", do cosmetic or low income medicine, etc. That is, if you don't fill your off time with hobbies like travel, investments, missions or sports you can start a profitable part0time business. It was very exciting to learn that there are still many opportunities opened in medicine if I get burned out or bored with shift work.
The last thing we discussed was Osteopathic EM Board certification versus Allopathic. It sounds like Osteopathic Residency programs allow you to sit for either Board test. So I could do the four year program at Arrowhead's Osteopathic Residency program, but sit for the Allopathic Boards. The difference between them is that the Allopathic Boards is more recognized internationally and probably required to teach at any Allopathic Medical school. The Osteopathic Boards would be required to teach at any Osteopathic school presumably. However, either allows to you practice anywhere in the U.S.
The first three days this week were in the Dupont ER were slow. Felt like an urgent care clinic with the ability to admit the most serious patients. I basically just did a lot of history taking, looking at labs and X-rays/CTs and hoping to see something interesting coming in on the monitors. Yesterday was a nice change and really peaked my interest in EM again.
This happened at the same time I was having great dinners with the Family residents courtesy of local drug reps. Wednesday we had a ton of pretty good sushi at the "best" sushi place in town. Lat night it was a top-rated steak place. The shrimp was ok. And I only got a few strange looks for being the only one of about 50 people not ordering red meat. The residents here are great people, so it was hard to admit my preference for EM as they were soft selling the program to me.
Today I slept in and am just getting started studying surgery. Less than 24 hours left in Fort Wayne. Kind of bittersweet. I can't wait to see the family, but I like the people here and am facing a very hard three months upon my return. We got our Clinical Education schedule from AZCOM this week and I can definitely see why the previous med classes despise the Department. My early summary of tests was a bit optimistic. I have Surgery and Family shelf tests, then a week later third year finals - one written and one with standardized patients. Then we get three weeks of 8 to 5 didactics immediately followed by our fourth year written final! The following four weeks I get to cram for the Osteopathic and Allopathic Boards. Seven tests in about 12 weeks.
My opinion during first year that Clinical Ed is probably the worst run Department at AZCOM has only been reinforced over the last year. Speaking of, before I study for these tests I have to make up (i.e. Lie) my logs for this rotation by inputting a bunch of ICM-9 and CPT codes on Clin Ed's worthless intranet site. They take up so much of our time and teach us nothing. And after ten years they still can't get us decent clinical rotations. The only redeeming value is a few superstars like Linda, the MSIII rotation coordinator who works her butt off for us.
Friday, April 20, 2007
Sunday, April 15, 2007
Fort Wayne Family Residency
The second week of inpatient family went great. I can't say enough great things about Dr. Connerly and the FP residency program here at Fort Wayne. I'm surprised it's not a lot more competitive than it is. Everyone talks about the Memorial program in South Bend as the big competition, but the only reason they are competitive is that they pay $11,000 a year more than Fort Wayne! And Fort Wayne pays relatively well, it's just that Memorial is the top paying FP program in the country. Oh, and you do sports medicine with the Notre Dame football team :).
Fort Wayne is better, from what I can tell, in terms of didactics, Night Float, hours for moonlighting, opportunities for moonlighting and pathology (tertiary ctr vs. community ctr). The Residents are trying to address the pay difference. And the Program will have a brand new 30,000 sf clinic open next May and a new regional hospital they will be moving into starting next year and completing in 2011. I even got on local TV this week with a few Residents, the Program director, hospital CEO and Mayor to announce the new building project at a press conference.
Speaking of pathology though, I saw the worst case of lymphedema ever here. It was elephantitis like we saw in Path class from photos taken in Third World countries. Oh, it also smelled like necrosis. We eventually got 19 liters of fluid off him so he could walk again! That's about 45 pounds off one leg! It still probably weighed 80 to 100 pounds, but he could get around with a walker when I left the service.
This is an environment where I could feel comfortable learning inpatient medicine. No comparison with the VA hospital.
Last week I was at St. Joe's hospital for OB/Gyn. It has been a great refresher. I delivered a couple babies, did lots of pelvic exams, did a couple circumcisions, got in on one C-section and rounded on lots of new moms and babies. I saw 14 year olds give birth, nuchal cords and even got to suture a very large second degree tear. We even had one nuchal cord rupture, one shoulder dystocia (with a fractured clavicle) and one muconium aspiration. As at Parkview over the past two weeks, the Residents and Attendings have been terrific. The main Attending, Dr. Pebble, is an admitted dinosaur.
Dr. Pebble is a Family physician that does general anesthesia, general surgery, Gyn surgery, OB and has his own family practice! He's like a walking legend. I bet there's less than a dozen docs like him left in the country. Heck, he even does anesthesia for friends doing heart surgery and learned laproscopic surgery on his own! Oh, did I mention he's also very cool and a great teacher?
I started getting gentle pressure to apply to the program if I decide on Family. I also attended a drug rep dinner and a welcome back party for one of the Docs returning from Iraq. It was a chance to meet many of the existing Residents and some of the new ones coming on next year. Everyone was very friendly. I also had a chance to hear more about ER work as a family doc. One of the Family Residents has an offer for $126 an hour plus benefits as a hospital employee in a small community. No call, no pager, 36 hours a week and a reasonable mix of day and night shifts. Not bad!
I'm presently studying for my second try at the surgery shelf exam. I missed passing the last one by two questions. After a conference call with the Dean, I would have passed if I hadn't changed some answers! I didn't criticize him for the poorly written questions, mostly because these results don't play into our Residency applications. It's just pass or fail. Kinda sucks anyway, because I had hoped to be studying Emergency for next week and/or Boards which will help for my last shelf exam - Family Medicine. I now have to take that after the last rotation.
In the next three months, I have two shelf exams, one standardized patient exam, third year finals and two sets of Step 2 Boards! Gotta love medical school, especially as a D.O. I had planned on just taking our required Osteopathic COMLEX Step 2 Board exam, but fourth year friends who just matched said that we need to take the Allopathic version (USMLE Step 2) if we are planning to apply for anything vaguely competitive, such as Emergency. So that's more stress, more time and another $500! This D.O. thing is sure getting expensive and time consuming. I mean I like OMM (manipulative medicine), but twice the Board tests, about twice the money (private vs. a state school) and 200+ extra lecture hours is adding up.
On the plus side, I did get to do some soft tissue techniques and HVLA on a couple of the MD Residents, which they loved. It's a handy skill for family, friends and patients but I'm not sure it's worth the cost at this point.
I forgot to mention the weather. It's been snowing the last few days! Very wet and windy. We finally got some sun this weekend. One of the Docs mentioned Fort Wayne is in a convergence zone of the Great Lake and Canadian weather patterns so it actually has fewer sunny days than Seattle! They made a new record earlier this year with 96 days of cloudy weather - yuck!
One more week in the ER. I'm sure missing the family, especially over the weekends. At the same time I'm concerned one week in the ER just isn't enough time to make a 20-year career decision. By the time I get to EM audition rotations in the Fall, changing directions will be much more difficult. I'm just going to try to make the most of next week, starting Monday at 9am...
Fort Wayne is better, from what I can tell, in terms of didactics, Night Float, hours for moonlighting, opportunities for moonlighting and pathology (tertiary ctr vs. community ctr). The Residents are trying to address the pay difference. And the Program will have a brand new 30,000 sf clinic open next May and a new regional hospital they will be moving into starting next year and completing in 2011. I even got on local TV this week with a few Residents, the Program director, hospital CEO and Mayor to announce the new building project at a press conference.
Speaking of pathology though, I saw the worst case of lymphedema ever here. It was elephantitis like we saw in Path class from photos taken in Third World countries. Oh, it also smelled like necrosis. We eventually got 19 liters of fluid off him so he could walk again! That's about 45 pounds off one leg! It still probably weighed 80 to 100 pounds, but he could get around with a walker when I left the service.
This is an environment where I could feel comfortable learning inpatient medicine. No comparison with the VA hospital.
Last week I was at St. Joe's hospital for OB/Gyn. It has been a great refresher. I delivered a couple babies, did lots of pelvic exams, did a couple circumcisions, got in on one C-section and rounded on lots of new moms and babies. I saw 14 year olds give birth, nuchal cords and even got to suture a very large second degree tear. We even had one nuchal cord rupture, one shoulder dystocia (with a fractured clavicle) and one muconium aspiration. As at Parkview over the past two weeks, the Residents and Attendings have been terrific. The main Attending, Dr. Pebble, is an admitted dinosaur.
Dr. Pebble is a Family physician that does general anesthesia, general surgery, Gyn surgery, OB and has his own family practice! He's like a walking legend. I bet there's less than a dozen docs like him left in the country. Heck, he even does anesthesia for friends doing heart surgery and learned laproscopic surgery on his own! Oh, did I mention he's also very cool and a great teacher?
I started getting gentle pressure to apply to the program if I decide on Family. I also attended a drug rep dinner and a welcome back party for one of the Docs returning from Iraq. It was a chance to meet many of the existing Residents and some of the new ones coming on next year. Everyone was very friendly. I also had a chance to hear more about ER work as a family doc. One of the Family Residents has an offer for $126 an hour plus benefits as a hospital employee in a small community. No call, no pager, 36 hours a week and a reasonable mix of day and night shifts. Not bad!
I'm presently studying for my second try at the surgery shelf exam. I missed passing the last one by two questions. After a conference call with the Dean, I would have passed if I hadn't changed some answers! I didn't criticize him for the poorly written questions, mostly because these results don't play into our Residency applications. It's just pass or fail. Kinda sucks anyway, because I had hoped to be studying Emergency for next week and/or Boards which will help for my last shelf exam - Family Medicine. I now have to take that after the last rotation.
In the next three months, I have two shelf exams, one standardized patient exam, third year finals and two sets of Step 2 Boards! Gotta love medical school, especially as a D.O. I had planned on just taking our required Osteopathic COMLEX Step 2 Board exam, but fourth year friends who just matched said that we need to take the Allopathic version (USMLE Step 2) if we are planning to apply for anything vaguely competitive, such as Emergency. So that's more stress, more time and another $500! This D.O. thing is sure getting expensive and time consuming. I mean I like OMM (manipulative medicine), but twice the Board tests, about twice the money (private vs. a state school) and 200+ extra lecture hours is adding up.
On the plus side, I did get to do some soft tissue techniques and HVLA on a couple of the MD Residents, which they loved. It's a handy skill for family, friends and patients but I'm not sure it's worth the cost at this point.
I forgot to mention the weather. It's been snowing the last few days! Very wet and windy. We finally got some sun this weekend. One of the Docs mentioned Fort Wayne is in a convergence zone of the Great Lake and Canadian weather patterns so it actually has fewer sunny days than Seattle! They made a new record earlier this year with 96 days of cloudy weather - yuck!
One more week in the ER. I'm sure missing the family, especially over the weekends. At the same time I'm concerned one week in the ER just isn't enough time to make a 20-year career decision. By the time I get to EM audition rotations in the Fall, changing directions will be much more difficult. I'm just going to try to make the most of next week, starting Monday at 9am...
Sunday, April 01, 2007
First week in Fort Wayne
Yup, people are nicer in rural America. Fort Wayne isn't small, at about 250,000, but it has a small town feel. As with most of the Midwest, it lacks the outdoor activities I'm used to, but it's a nice size. And whereas the music was scene in Toledo was Country and Ghetto, here it's just Country. Not my favorite, but it's easier to overlook than awful traffic, mean people and outrageous home prices.
As for the medicine, the Residents and Attendings are some of the best I've worked with so far. I'm really impressed by this Family program so far. A PYGII (2nd year Resident) wants to do OB/Gyn when she's finished. The Program has managed to get her 69 C-sections so far!! Her husband wants to do Emergency. The two understand they will have to live in a small community, probably under 50,000, most likely. But it's an attractive plan.
The hospital, Parkview, is a tertiary care (Trauma Level II) center for a big area and even here Family Medicine Docs handle much of the ER. There's an acute care ER where they have to have an EM Boarded Doc on at all times. But five FM graduates of this program help to staff the three ERs.
Yes, my schizophrenia has returned and I seem to change my mind a couple times a day. But when we take new admits in the afternoon and I do an H&P in the ER I always up thinking EM. In fact, I've got Arrowhead's EM program lined for a September "audition rotation". And I filled out my paperwork for Maricopa's ER rotation before anyone else so I should be able to get August there. One more ER rotation in October or November at an East Coast program, like Christiana or Augusta, should do the trick. Then I'll just have to apply to 30 or so Programs and interview at no less than 12 to "guarantee" a spot without scrambling.
We usually get together around 7am, divy up new patients and get updates on our ongoing patients from the Night Float Resident. Then we see patients and round until 10am when we have Attending Rounds. These are relaxed and great educational lessons by Dr. Connerly. We then have a quick lunch and put in our new orders (from Dr. Connerly's input) before two of the three Residents head to Clinic. The other student and I stay with the Resident on "Call" taking new admits until 6pm when the Night Float Resident comes in for turnover. Night Float is a great system!
This is how to learn about Medicine! I have no desire to be a Hospitalist, but this program really teaches FPs how to be Docs. They only have two half days of clinic first year, then a day and a half second and third years, but they still acquire way more than the required number of patient encounters for the FP Boards. The time most programs spend in Clinic, these guys spend learning procedures, internal medicine and electives in OB, ER, scopes, etc. And for students it's great as well. We even get to write orders and dictate notes. This is my first opportunity at either, and it feels like a huge head start on Internship.
Finally, I'm really glad to have a car. It's required since my apartment is a few miles from the hospital and I'm going to be doing OB and ER in different hospitals. But regardless, I don't want to be trapped like I was in Toledo again. I'm studying in a coffee shop with free WiFi at the moment. Had time to get a haircut and drop off dry cleaning yesterday. And a few days a week I'm swimming at a local pool for about $1.50 a session.
As for the medicine, the Residents and Attendings are some of the best I've worked with so far. I'm really impressed by this Family program so far. A PYGII (2nd year Resident) wants to do OB/Gyn when she's finished. The Program has managed to get her 69 C-sections so far!! Her husband wants to do Emergency. The two understand they will have to live in a small community, probably under 50,000, most likely. But it's an attractive plan.
The hospital, Parkview, is a tertiary care (Trauma Level II) center for a big area and even here Family Medicine Docs handle much of the ER. There's an acute care ER where they have to have an EM Boarded Doc on at all times. But five FM graduates of this program help to staff the three ERs.
Yes, my schizophrenia has returned and I seem to change my mind a couple times a day. But when we take new admits in the afternoon and I do an H&P in the ER I always up thinking EM. In fact, I've got Arrowhead's EM program lined for a September "audition rotation". And I filled out my paperwork for Maricopa's ER rotation before anyone else so I should be able to get August there. One more ER rotation in October or November at an East Coast program, like Christiana or Augusta, should do the trick. Then I'll just have to apply to 30 or so Programs and interview at no less than 12 to "guarantee" a spot without scrambling.
We usually get together around 7am, divy up new patients and get updates on our ongoing patients from the Night Float Resident. Then we see patients and round until 10am when we have Attending Rounds. These are relaxed and great educational lessons by Dr. Connerly. We then have a quick lunch and put in our new orders (from Dr. Connerly's input) before two of the three Residents head to Clinic. The other student and I stay with the Resident on "Call" taking new admits until 6pm when the Night Float Resident comes in for turnover. Night Float is a great system!
This is how to learn about Medicine! I have no desire to be a Hospitalist, but this program really teaches FPs how to be Docs. They only have two half days of clinic first year, then a day and a half second and third years, but they still acquire way more than the required number of patient encounters for the FP Boards. The time most programs spend in Clinic, these guys spend learning procedures, internal medicine and electives in OB, ER, scopes, etc. And for students it's great as well. We even get to write orders and dictate notes. This is my first opportunity at either, and it feels like a huge head start on Internship.
Finally, I'm really glad to have a car. It's required since my apartment is a few miles from the hospital and I'm going to be doing OB and ER in different hospitals. But regardless, I don't want to be trapped like I was in Toledo again. I'm studying in a coffee shop with free WiFi at the moment. Had time to get a haircut and drop off dry cleaning yesterday. And a few days a week I'm swimming at a local pool for about $1.50 a session.
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