3. Epidemiology/Intro In 1979, Emergency Medicine became a nationally recognized medical specialty 1988 – Last year for physicians to practice under “grandfather clause” Currently, the demand for board certified EP is ≥ 20,0000 Probably will not be achieved till next century Rural >>> Urban/Suburban
5. Factors That the Demand for Emergency Physicians Aging of US population General in US population Greater demand of the public for ambulatory care services, but insufficient non-ED alternatives Demonstration that improved clinical outcomes are assoc w/ emergency medicine trained EPs Expansion of out-of-care hospital services/systems Employment of US trained EPs in emergency health care facilities outside the US
6. Factors That Demand for Emergency Physicians Closure of hospital EDs Use of “physician extenders” in place of EPs Refusal of payers to fund nonclinical duties by EPs Transfer of ambulatory care cases currently managed by EpPs to primary care practitioners outside the ED
12. Why do they leave the Field… (1) AMA quotes the attrition rate for most medical specialty is about 2-3% For EM: 1.5 to >12% Anwar, RAH (1983) reported in his study: 5% attrition rate 2 years after EM residency training
13. Why do they leave the Field… (2) Physicians who left the field Long and irregular work schedule Financial stability Academic vs on your own Single vs married Board certification STRESS
15. Length of Shifts “Length of the shift should depend on the physical and mental load of the task” - Kanauth and Rutenfranz. J Human Ergol 1982 (11)
16. Length of Shifts (1): 8 hours vs 12 hours In a manufacturer of synthetic yarn (Laundry & Lee) Accidents when shifts changed from 8 to 12 hrs In an oil refinery plant (Gardner & Dagnall) No change in days lost due to sickness and injury Study of 50 chemical companies (Kanauth & Rutenfranz) No increase in accidents
17. Length of Shifts (2): 8 hours vs 12 hours In a ammunition/explosives plant (Vernon) Accidents increased when working 12 vs 8 Review of all taxi drivers (Nozawa) Fewer accidents seen in 8 hr shifts Study of all aircraft accidents and electrical power plants (Kelly & Schneider) Increase in human errors when worked beyond 8 hrs Due to fatigue and circadian upsetg]
20. Length of Shifts (3): 8 hours vs 12 hours In a study with residents (Steele et al) 73% preferred 8hr shifts; 21% preferred 12 hr Residents preferred evening/night shifts No kids Younger age Have flexible sleep patterns Love night shifts Quick ability to overcome drowsiness
21. Length of Shifts (4): 8 hours vs 12 hours Advantages of 12 hrs Fewer shift changes Fewer transfer of pt care Longer time period for patient care Less time working after shift change Less commuting time 1/3 more days completely off Advantages of 8 hrs More rest alertness in the last 2-4 hrs Ability to participate in personal activities on workdays Ability to apply circadian principles in rotating shifts
22. Length of Shifts (5): 8 hours vs 12 hours Final thoughts about optimal shift ED census Stress level of work Scheduling concerns (double coverage, # of nights) Group size Weekends vs weekdays Social times Family time
23. What do YOUR fellow PEERS/ Colleagues have to say?
24. Assessment of EM Graduates Pereception of the Adequacy of Their Training Highest Rated Resuscitation and stabilization Principles of emergency care General assessment Ability to treat multiple patients Ability to provide timely care Lowest Rated Physician interpersonal skills Disorders related immune system Cutaneous disorders Hormonal, metabolic, and nutritional disease Administration/hospital politics
25. Advice From Your Fellow Colleagues at ACH (1) Get the nurses on your side (D. Girzadas) “it’s like starting residency all over again…” Show up early or on time (H. Zerth) “or colleagues will resent you forever” Things move faster than ACH, have a plan before leaving the patient room (H. Zerth) “adding on tests after tests will delay disposition for 2-3 hrs and are generally frowned upon”
26. Advice From Your Fellow Colleagues at ACH (2) Don’t be afraid to ask your senior co-attending a question (D. Strasburger) “asking for a second opinion is not forbidden” It’s not as hard to admit someone (H. Zerth) “don’t fight tooth and nails, if you aren’t comfortable discharging someone then admit” You are going to be nervous (H. Zerth) “just trust your training and you will do fine ”
27. Advice From Your Fellow Colleagues at ACH (3) Ask for an orientation of your ED (C Kulstad) “never want to be in a situation where you have to look around for something in a hurry (central lines, ET tubes, chest tubes, etc)” Become a “good citizen” by asking how you could contribute (M.Felder) “allows you to find a nitche, both security and longevity”
28. Advice From Your Fellow Colleagues at ACH (4) Say thank you a lot, act like you want the business (S Altman) “when you are paid full salary, there is no such thing as an ‘inappropriate’ ED Visit” Be involved early and as much as possible(PJ Konicki) “get to know as many attendings outside the ED” “attend social and charitable events run by hospital and medical staff office” “Make ED consultation friendly ”
29. Advice From Your Fellow Colleagues at ACH (5) Walk in the door calling your fellow attending by their first name (S Altman) “if you act deferential, you will be treated as a resident” Try to accept all requests for shift trades when possible, even if they don’t seem fair (S Altman) “you will become known as a team player” “just keep track of the shifts, beware of anyone who tries to take advantage of you”
30. Advice From Your Fellow Colleagues at ACH (6)- Shadow Shifts - Do a shadow shift in a place you are not familiar (A. Kiernicki-Sklar) “important to know how certain processes work before you start (e.g. transfer, admission, running codes, etc)” “allows you to be familiar with the kinds of equipment they have available” Need to know the competency of the staff around you (A. Kiernicki-Sklar) “ancillary staff may not know the medications you are familiar with” “will they be able to recognize a sick patient?”
31. Advice From Your Fellow Colleagues at ACH (7)- Watch your words- Listen first, talk last (T. Ross) Give advice/opinion ONLY when asked (T. Ross) Do not get in an argument for any reason – DO NOT raise your voice (T. Ross) “remember, you are under watch at all times” Never engage in any talk complaining about one of your colleagues (T. Ross) If someone asks, respond back by saying: “you haven’t noticed that, but how about them Bears”
32. Advice From Your Fellow Colleagues at ACH (8)- Watch your words- “I think you will find that if you stop complaining you might not need to do it as much anymore. One you start, it is hard to stop. Think of complaining like cigarettes and stay away... (Oh, how I would love to have a smoke!!)” (T. Ross)
33. Advice From Your Fellow Colleagues at ACH (9)- Financial Help- Live like a resident for 2 more years (S Altman) “a dollars saved today is worth more than one saved tomorrow” “put off that temptation of buying that Lexus/Porsche” “ONLY EXCEPTION IS BUYING A HOUSE” Maximize tax deferred opportunities(S. Altman) “money saved in this account is untouchable in case of divorce, law suit, or even criminal activity” Look for a good team to manage your investments/retirements/disability (A Katiyar)
35. Upcoming Events/Notice LAR Dinner on February 8th, 2010 Place: TBA Topic: TBA For 3rd years, have your contract reviewed by someone Contact Mila for any help For 2nd years, start working on your CV Contact anyone of us for help/guidance
36. References Hall, KN et al. Factors Associated with Career Longevity in Residency-Trained EP. Annals of EM. March 1992 (21:3) Holliman CJ et al. Workforce Projections for Emergency Medicine: How Many Emergency Physicians Does the United States Need?” Academic Emergency Medicine. Vol 4 (7), Sept 2008 Moorhead, J et al. An Assessment of EM Residency Graduates’ Perceptions of the Adequacy of Their Residency Training. Annals of EM. June 1989 (18:6) Thomas, H et al. Eight-Versus 12 Hr Shifts: Implications for Emergency Physicians. Annals of EM, May 1994 (23:5) Steele, M et al. Emergency Medicine Residents’ Shiftwork Tolerance and Preference. Academic Emergency Medicine. Jun 2008, vol 7 (6) http://www.aaem.org/media/updates_content.php?contentid=263 http://www1.salary.com/ER-Physician-salary.html http://www.careermd.com/employers/ci_em.shtm http://money.cnn.com/magazines/moneymag/bestjobs/2009/snapshots/70.html
