Emergency Medicine Residency Survival Guide


THE CHALLENGE OF EM

Introduction. This guide details my experiences and my advice alone, it does not necessarily represent the DOD nor any of its components. My educational road was somewhat circuitous and unconventional. I completed a Transitional Internship in 2012-2013 at Naval Medical Center Portsmouth (NMCP) before the categorical Emergency Medicine (EM) internship existed. After internship, I trained and served as a Navy Dive Medical Officer (DMO) for three years before returning to EM residency in 2016. During my final year, I served as the Academic Chief of our residency program until graduation in June 2019. This advice is an accumulation of my thoughts and ideas about how to survive, but also how to thrive during EM residency. Much of this information is geared specifically toward my people – Navy EM Residents – but many of the general principles can be applied to civilian residency as well. Much of what is discussed below is theory or mindset, there are occasionally specific tips and recommendations, but for more detailed gouge, please seek out your local leadership. Residency can be daunting, hopefully this provides you with helpful information and quality resources. Also, random pictures from our unique residency experience are inserted throughout this guide. Enjoy!

NMCP EM residents working their magic on the USNS Comfort.

Knowledge, Procedures, Logistics. The challenge and the practice of emergency medicine is unique in that you must master a massive breadth of knowledge that involves the most critical presentations of every specialty. You must also establish competence in a diversity of procedures, and you must learn to apply that knowledge and those procedures in your hospital system with incredible efficiency. The EM skillset spans from primary care to the hyperacute critically ill patient, from pediatrics to geriatrics, and every acuity and age between. In one moment you will resuscitate a cardiac arrest, and then you will intubate a crashing respiratory failure. Then you will walk into the next room and perform a simple laceration repair, then console a mother who miscarried in her first trimester, then reassure a parent that her child with a fever is very well appearing and likely has a virus that needs to run its course. These patients must all be cared for simultaneously after mentally triaging and rapidly prioritizing. In this world, task switching is key, the variety is intense, the intensity is varied, and efficiency is king. We are by convention generalists in all specialties, but we specialize in acute stabilization. Or, as an EM physician, per our class mantra, I am a “Jack of all trades, Master of resuscitation.”

NMCP EM residency conference space.

Problem Solving. Despite constant training and countless patients, nearly every shift challenges the EM physician with new complexities never before encountered. This dynamic mandates that we be problem solvers. Whether the problem is medical, logistical, consultant related, or an equipment deficiency, the emergency physician must adapt readily and find solutions quickly.

Jack of all trades, Master of Resuscitation.

NMCP EM Class 2019

Decision Making. While we may never intimately understand the inpatient and outpatient environments of our consultant colleagues, we must master that nebulous, gray emergent world in between where the crashing, undifferentiated patients require a calm mind and a steady hand. We regularly act decisively on limited and often ambiguous information, and when the smoke clears and clarity prevails, some criticize our actions. But when time is scarce, our world is dominated by gestalt, by pattern recognition, by thin slicing, by type one thinking – we are biased to act. For the truly sick and injured require immediate action, they require procedures, interventions, and resuscitation. Only after initial stabilization of the critically ill do we allow a more cerebral, type two thinking pattern. But this cerebral analysis, if entertained too early, paralyzes the physician, kills patients, and grinds the entire ER flow to a halt. We see the initial acute undifferentiated presentations of every disease, so we train to react instinctually to specific disease patterns, and to think “worst first.” Once killer diagnoses are excluded, then we can address lesser issues. But we MUST make decisions, and we must make them quickly. Someone once said, “MD” means “Make Decisions,” this can be no more true than in the Emergency Department.

NMCP EM resident showing an Army EM resident how it is done.

Teamwork. Working together effectively and efficiently as a team is paramount in the ER. Knowing your team, their names, their capabilities, their roles, your role, the patient, the patients’ needs, your facility, your infrastructure, your consultants, your ancillary staff and how to best facilitate each individual to provide optimized care to each patient is vitally important. Each system takes a while to learn, and longer to master, but expediting this learning process is key due to our ultimate reliance on the efficiency of processes. Even studying your consultants’ personalities and their workup preferences improves work flow. Refining these efficiencies and integrating with your ER team and the hospital staff takes time, but learning to operate as a finely tuned team is highly rewarding both personally and professionally. You MUST be a team player as an ER physician. Often this means compromise, and it often means swallowing your own pride to accomplish what needs to be done. Some battles are not worth fighting, but some are. So choose wisely. Teamwork makes the dream work.

You MUST be a team player as an ER physician.

Military EM. Military EM is the pinnacle of the practice of emergency medicine. Not only must we excel at resuscition in civilian facilities, but we must also master bleeding edge combat trauma management. When deployed, we manage complex injuries and wounding mechanisms rarely encountered in the US – penetrating trauma from multiple high velocity rifle rounds, devastating burns and blast injuries from improvised explosive devices, horrific mass casualty incidents, and obscure conditions only encountered in third world countries and in extreme environments. And we frequently practice in austere and resource limited settings while occasionally exposed to personal injury. As military physicians, we must be decisive and adaptive. Our residency program will train and equip you for these challenges like no civilian residency is capable of doing. Throughout residency, you will have opportunities to pursue training in operational medicine, and you will participate in multiple military training exercises – Bushmaster, Operation Gunpowder, the Humanitarian Assistance and Disaster Relief Course, USNS Comfort deployments, Mountain Medicine, Dive Medicine, Tropical Medicine, and unit specific operational rotations. Some of these opportunities are only available if pursued, but your leadership will support you, so pursue aggressively. The yearly Military Unique themed block will focus on the nuances of military EM, drink this up and learn as much as you can. Someday, your fellow service members will trust your unique clinical acumen to protect them in that foreign, austere, and resource limited setting.

NMCP EM residents managing an amputation during the final residency exercise – JEMX.

ROTATIONS

During residency, you will rotate through many ERs and various specialties, the exact details are fluid, but the core blocks and block durations are constant. As an NMCP EM resident, you will spend the majority of your time in our ER and in the surrounding community ERs, but the remainder of your rotations are electives or off-service blocks. During internship, you only work one or two months in the ER, everything else is off-service, but this ratio changes as you progress through residency. By your final year, you will spend half of the academic year in the ER, so if you feel that you do not get enough ER exposure as an intern, don’t worry, your time will come. Specific rotation gouge for each of these locations is found on the residency website.

General representative of the blocks of our residency.

NMCP EM. During NMCP ER blocks, I recommend that residents focus primarily on learning to manage large volumes of patients efficiently. The five different EMRs that must be utilized simultaneously during a shift can complicate matters, but if you can work efficiently in our ER, you can do it anywhere. You will also encounter a large number of pediatric patients and female OB/GYN complaints, so you will become a master of the kiddos and the pelvis. This is also our home academic ER, so the staff actually care about your education and will teach you, enjoy this and maximize this time. Pick their brains about the nuances of their practice, absorb as much as possible and craft your own patterns accordingly.

The code cart, quietly waiting.

Outside EM. The predominantly low acuity at our own institution necessitates frequent outside rotations at civilian ERs. These months are the highlights of residency due to the high acuity, the procedures, and the independence allowed. Many of these ERs do not have their own residency programs, so the staff attendings frequently offer you intubations, central lines, chest tubes, and other procedures. This allows them to continue seeing new patients, and you get more experience with EM critical care – a win win situation. Once they trust you, they allow significant independence, which is awesome during 3rd and 4th year, but is somewhat intimidating during your first few years. So ask questions and actively seek their help if needed. I recommend that residents not focus on volume during these rotations. Focus on cherry picking high acuity patients – that is why you are there. If you continue crushing patients like you do at NMCP, then a trauma or a resuscitation will arrive and you will be unavailable, so leave some bandwidth free for critical patients and procedures. This may feel awkward at times since we are trained to aggressively see new patients, but get over it. You need critical patients, and you will see them at these outside ERs. Maximize those opportunities. Rumors of NMCP becoming a trauma center are circulating (although these rumors were ongoing when I was an intern seven years ago), and we recently opened the gates to civilian ambulance runs, so hopefully the acuity at NMCP will improve. But until then, proceed as per above.

Trauma. We rotate one month of internship and one month of EM2 across the water at Sentara Norfolk General Hospital (SNGH), the Level 1 trauma center for the region. We previously rotated a third month at SNGH during EM3, but recently transitioned to a hospital near Chicago to get a different trauma experience. During these months, you will see a lot of blunt force trauma and occasionally penetrating trauma. You will serve as a part of the trauma team, have various rounding and floor duties, and respond to the trauma bay whenever the PA system announces an incoming trauma. You will learn bread and butter trauma assessment and management, and through the sheer volume of patients evaluated, the ATLS algorithm will become second nature. Unfortunately, as junior EM residents, you will rarely be involved in the big picture decision making, this is delegated to the senior surgical resident running the service. So focus on making trauma evaluation instinctual, perform as many procedures as possible, and then exercise these skills during your next EM rotation.

Focus on making trauma evaluation instinctual, perform as many procedures as possible, and then exercise these skills during your next EM rotation.

You will also spend two months at Riverside Regional Medical Center and one month at the University of Florida, Shands, in Jacksonville. At Riverside, a Level 2 trauma center, you will manage the traumas with the ER attending and the nursing staff. This is phenomenal for your leadership development, especially during the last few years of residency. During EM3 and EM4, completing one more month of trauma at Norfolk General as a cog in the wheel of the trauma team is not necessarily furthering your education nor preparing you well for your future practice, so the management independence and decision making experiences offered at a smaller trauma center matures you much more as an EM physician. During the month at Shands, you will run the resuscitation unit and manage all of the trauma activations. This is a phenomenal experience. You will see severe traumas without the volume of SNGH, and you will be involved significantly in management and decision making. After all of these months of trauma and the variety of experiences at different locations, you should feel very confident in caring for traumas independently at whatever ER you eventually practice.

NMCP EM resident healing the wounded during our end of residency exercise – JEMX.

ICU. The critical care rotations were some of my favorite experiences, especially at Norfolk General. You will spend a month in the SNGH ICU as a junior resident and another month as a senior EM resident. As the senior resident, you will manage the ICU overnight alone with an intern and occasionally with another resident. The independence and management experience is incredible. You will also respond to codes in various areas of the hospital, and occasionally run them. Everything in the General ICU is your responsibility, and you will frequently manage very sick patients that require all of your accumulated experience. The critical care fellows are on call overnight and are always available, but they respond from home and you should be able to handle most scenarios without them. During the days, you will round as a part of the ICU team and receive excellent teaching from the attendings and fellows. Overall, these ICU months are invaluable experiences that will ultimately make you a much better EM physician.

In the ER, airway is king, and we must be the wizards of difficult, bloody, vomitus, young, old, and traumatic airways.

Anesthesia. Spending time with the anesthesiologists and intubating patients in the controlled setting of the OR is likely the singular most important experience for a budding EM resuscitationist. In the ER, airway is king, and we must be the wizards of difficult, bloody, vomitus, young, old, and traumatic airways. These months at NMCP and Riverside will make you competent and possibly even good at intubating. During my rotation, I primarily performed direct laryngoscopy (DL), which solidified many of the microskills associated with intubating and paved the way for future success with video laryngoscopy (VL) – which I found incredibly easy after DL. Make the most of these experiences, I found that airways are earned, not given – discuss the cases with the anesthesiologists and CRNAs, introduce yourself to the patients and help prepare them for the OR, find the optimal rooms and operations for potential intubations, and perform well early so that they trust you with future airways. Much of your success during these months depends on your personal motivation. Overall, these rotations are foundational to your airway success in EM.

A casual conversation with EM toxicology great Dr. Lewis Goldfrank.

Toxicology. This is easily the most popular month in our residency, this rotation during fourth year is simply amazing. During the day, you will follow up on patients whose providers consulted the NYC Poison Center, digest lectures from toxicology gurus – including Dr. Lewis Goldfrank, and discuss various toxicology topics as a group. During the evenings and weekends, you are free to explore New York City in all of its glory. The work room is in the New York City Poison Center directly across the street from Bellevue Hospital on the East Side of Manhattan Island. From there, it is a short walk or subway ride away to most of the excitement of New York City, and the restaurants are everywhere and incredible.

Electives. These can be amazing months, let your imaginations run wild. Some residents complete courses in Mountain Medicine and Cold Weather Medicine. Some pursue rotations in specialties that will make them better EM physicians – pediatrics anesthesia, ophthalmology. Others spend the month in ERs close to their homes. So think big, do something interesting, do something that you may never have the chance to do again in your career.

Global Health. This program is a phenomenal opportunity for those interested in global health. This is a funded scholarship tract for 1-2 residents per year, and those involved have traveled to Vietnam, Hawaii, India, participated in humanitarian missions on the USNS Comfort, and assisted in teaching various courses at Harvard and in Washington DC.

Ruck Run aftermath at the Mountain Medicine Course in Bridgeport, California.

Others. You will also complete rotations in General Surgery, Internal Medicine, Orthopedics, and Obstetrics. During these rotations, learn everything that you can from our consultant colleagues about their specialties and their practices, then incorporate those lessons learned into your own practice in the ER to make you a better EM physician, colleague, and informed consulter. Learn what they want when they are consulted, each have their own peculiar wishes and practices. The better you learn their nuances, the better your relationship with your consultants will be. Often, you will perform their duties yourself in small Navy and rural civilian ERs, and refer the patients to them in the outpatient setting. So learn as much as you can before you are on your own.

The beautiful NYC skyline and Brooklyn Bridge during the month long Toxicology rotation.

SHIFT MAGIC

Learning how to navigate a shift efficiently and effectively is the magic of emergency medicine residency. There are a variety of approaches, but my own personal practice and what I expected of junior residents as the Academic Chief is detailed below. Much of this is specific to our NMCP ER and its demographics, but this is also where you will spend most of your EM time.

Learning how to navigate a shift efficiently and effectively is the magic of emergency medicine residency.

Volume. Our shifts are scheduled for eight hours, but expect AT LEAST one hour extra of turnover and admin. As an EM intern, once you figure out our system and become more efficient, you should see approximately eight patients per shift, especially as you near the end of your EM rotation or approach the end of your intern year. As an intern, you should focus on the quality of patients and learning how to work up the most commonly encountered chief complaints. Later you can focus on quantity. As an EM2, during the first half of the year, you should see around ten to twelve patients per shift, again, focusing on the quality of the patients and solidifying your EM knowledge base. Constantly seek out the sick patients requiring a higher level of thinking and care. By the last half of your second year, you should start pushing your volume to beyond twelve and attempt to see nearly fifteen patients. This will prepare you for the initial beat down that third year brings. At this time, you are also allowed to start proctoring medical students during your shifts, which helps you explore your system in preparation for the next year.

Constantly seek out the sick patients requiring a higher level of thinking and care.

As an EM3, you go from a happy, low responsibility second year, where you were focusing only on your personal learning, to suddenly managing the department, proctoring interns and medical students, and vastly increasing your volume beginning July 1. This is a massive and difficult transition for some, but the better you prepare for that moment, the easier the transition. As an EM3, in our department, you regularly see between twenty and thirty patients in an eight hour shift, and sometimes more. During this time, efficiency is crucial. So the sooner you figure out your processes and flow, the better. As a fourth year, nothing really changes from third year, you are just much better and faster at seeing patients, and what previously seemed like an overwhelming shift will seem easy.

Winning the game. Rarely do we wipe the board clean, so it is a time to celebrate.

Turnover. Transition points have been established as the most dangerous periods of patient care. Learning the art of the turnover is necessary to becoming a competent resident and capable physician. Turning over and receiving turnovers require skill. A few salient points:

  • The culture of turnover varies widely depending on the facility, but I encourage you to turnover patients and to receive turnovers willingly. Some institutions and individuals don’t want any turnovers, but want the departing provider to disposition all of their patients. This is harmful for a few reasons. It will fuel burnout when providers needlessly stay for hours after each shift waiting for labs/imaging/consultants to make a final disposition. It also discourages departing providers from picking up new patients near the end of a shift. This creates unnecessary length of stays, harms patients, and often provides a huge bolus of new, sometimes sick patients for the arriving providers. But refusing turnovers also hurts you. Your colleagues will be less willing to receive your turnovers, requiring you to stay late repeatedly, and lead to your own burnout. Again, I encourage you to receive turnovers willingly and to turnover your own patients willingly – with a few caveats.
  • If I am nearing the end of a shift and evaluate a patient that I know will require a lengthy workup and eventual turnover, I frequently am more conservative and order more labs/tests than my usual practice to ensure that nothing is missed and that the oncoming provider is comfortable with the workup. EM physicians differ significantly on their risk aversion and thoroughness of workups, so I adopt the practice patterns of my more conservative colleagues in this case. Then they are not required to completely trust my gestalt when discharging a patient with a somewhat risky complaint.
  • If there are loose ends that can be tidied quickly, then absolutely stay beyond your shift to help disposition, but try not to make staying late a habit. Also, if the ER is really busy and the arriving physician is getting crushed, help by staying behind temporarily to disposition patients and establish a tidy turnover.
  • The best turnovers have a specific plan and only need one or two tests to make a final decision – a delta troponin, a CT thorax for PE, i.e. “dispo per CT.” Often, you can prepare the discharge paperwork, print the outpatient prescriptions, and counsel the patient on the turnover and the plan. At that point, the oncoming physician needs only to follow up on that last test and say one last goodbye to the patient before pressing the discharge button. In some cases, since you know your patients best, you should also call the consulting physician to give a heads up if admission is anticipated. This will save much grief for your successors and allow them to focus on their own new patients in the busy ER.
  • In our NMCP ER, we follow a turnover format – resuscitation room usage, incoming patients, floor issues, equipment issues, consultant issues, sedation capability, and then we “run the board.” When you run the board, use a system – SBAR, I-PASS, or something similar – to discuss each patient. When receiving turnovers, take notes as needed. I found that quickly typing pertinent information in the comments section of our EMR was efficient. Then when turnover was complete, I would jot a quick note for each patient.
Mass Casualty exercise conducted with a Special Forces Group during JEMX.

Procedures. Once you decide that a procedure is necessary, whether diagnostic or therapeutic, you should prioritize that procedure on your task list. Many residents procrastinate for whatever reason – fear, inconvenience – and postpone necessary procedures that later become a hassle to perform and even more inconvenient. Rapidly mentally triage your patients, quickly evaluate your new patients, input necessary orders, place your patients into a holding pattern, and then do the procedure. When you are finished, some patients will be ready for a final disposition, and the others will be much closer to a completed workup. Rarely, if ever, should you turnover a procedure to an oncoming colleague. This is generally not appreciated, and it is not what is best for the patient.

Brand new EM interns learning how to splint during intern orientation.

Tracking. You must establish your own system for keeping track of your patients – who you have seen, who you need to see, what you need to do, what labs/tests are pending, etc. Some EMRs help more than others. Some of my colleagues collected books of stickers, I would encourage you to avoid this for a few reasons. You don’t want to violate HIPAA by losing your sticker book or leaving it places. Also, if busy, it slows you down. I tried this technique initially, but found that some nurses would bring me stickers and others wouldn’t, or there would be no stickers at bedside, or with critical patients I was too busy with other tasks to remember stickers, or stickers weren’t available because the patient wasn’t yet registered. After walking around the ER constantly looking for stickers, I finally realized that this was an inefficient practice and a waste of time. You can just track your patients through the EMR. If you occasionally need to save a sticker for a good case or a procedure or a resuscitation, then fine, but don’t establish a sticker crutch that ultimately slows you down. Also, run your board occasionally to ensure that you are not forgetting patients, or that patients whose workups are completed are not waiting too long for a disposition, or to ensure that you didn’t forget any part of the workup, or to encourage a patient to urinate – you will always be waiting for urine.

Also, if you are feeling overwhelmed, paralyzed by the volume of patients and pending procedures, then pause. Take a moment to center yourself, then prioritize and execute. Finish one task, then the next, then the next, and gradually dig yourself out of that hole. There were multiple times that I found this technique helpful, especially when I felt task overloaded and didn’t know where to begin.

Prioritize and execute.

Jocko Willink

Finally, minimize redundant note taking. At the beginning of residency, I carried a blank paper with me and occasionally took notes, eventually I abandoned this practice too. Note taking outside of the EMR, except for specific circumstances, slows you down. Exercise your brainpower. Listen to the patient, take your history, then repeat the abbreviated story to the patient to ensure understanding. After practicing this method with thousands of patients, your recollection for minutiae with specific patients is more than sufficient, even hours later. Redundant note taking is a crutch, and a waste of time. Save it for when you won’t remember specific data – a doctor’s name, a clinic, a phone number, etc.

Senior NMCP EM resident practicing TCCC during the final residency exercise.

Flow. Physicians flow differently throughout the ER, find what works for you. You can often tell how long you will be in a room by the chief complaint. Read the nursing notes, scan the vitals, check for previous visits or pertinent history before entering the room, this will make you much more efficient in the room. Some physicians see patients linearly – they evaluate a patient, start a workup and their note, then move to the next patient an repeat that pattern. Some physicians bolus their patients – they evaluate two or three before returning to their workstation. This practice his highly dependent upon the patient acuity or specific complaint though. Often, placing a few quick orders on multiple patients to initiate workups is warranted, especially if you are busy. Also, if EMS warns you about an incoming trauma or critical patient, place preliminary orders or discharge patients – time permitting. Some emergency departments initiate nursing orders from triage for common chief complaints. This can helpful, but also frequently requires additional studies after patient evaluation. Experiment with your flow, watch other physicians, find what works for you. And then work it.

Some residents approach graduation and experience significant anxiety, but this can be avoided by mentally practicing independently during the last few years of residency.

Mindset. Finally, as you enter your third and fourth year, imagine that there is no attending physician backup. Evaluate your patients and formulate plans as if you were practicing alone. Then, and only then should you discuss your patients with your attending. They may think differently or have additional concerns, but observing this practice will prepare you for practicing independently after residency. Some residents approach graduation and experience significant anxiety, but this can be avoided by mentally practicing independently during the last few years of residency. Also, every attending practices differently, this is often frustrating for residents. But instead of being frustrated, learn as much as possible from each attending. Then formulate your own practice patterns from those experiences, evaluation of the evidence, and your amalgamation of their practices.

Senior NMCP EM residents teaching ultrasound during the monthly intern practicum.

STUDYING

Knowing how to study during residency is difficult for a variety of reasons. We are very busy regularly working between sixty and eighty hours a week, we all learn dissimilarly, the various exams and boards mandate divergent study patterns, and study styles change throughout residency. Always remember though, you are a resident, and residency is supposed to be difficult, a constant bombardment and immersion in medicine. Learning EM should be your primary focus, and this requires diligence, discipline, and perseverance. Remember, residency is only a brief moment in time compared to the rest of your career, so work hard! Hard work pays off.

You are a resident, and residency is supposed to be difficult…but, hard work pays off.

Chronology. The early years of EM residency are grueling, there is so much to know. So you must focus on high yield information for a vast array of topics, but you must also read broadly and deeply to ensure a complete understanding. Finding this balance can be difficult, but EM interns must invest significant time into reading and studying. In our residency, following the reading schedule assigned by the program director and chiefs will cover the entirety of Tintinalli’s in two years. This can be daunting, but should be attempted. If you are limited on time, at least scan the assigned chapters, study the bold words and phrases, and peruse the tables. Supplement Tintinalli’s with high yield, concise material from review books and FOAM (Free Open Access Medical) Education – websites, and emergency medicine specific apps (see below). As residency progresses, the ratio of time spent with different sources will change. As you become familiar with more topics, less time can be spent in the texts, and you should invest more time into cutting edge literature, and dissecting the original literature upon which our foundational EM practices are based. Occasionally, you will need to dive deeply again into a topic for review, and this should be expanded to multiple sources, including texts, websites, and articles.

Senior NMCP EM residents teaching Damage Control Resuscitation to brand new EM interns during intern orientation.

Off-service. Off-service rotations can be difficult as well. Many of the inpatient rotations require long hours and there are few days off during the month. Thankfully, the shift intensity is rarely as brutal as an EM shift, so you can study during shifts occasionally. During off-service rotations, you should learn their approach to patients, pick their brains about topics in which they are subject matter experts, but always keep in mind that you are an EM resident. Much of what you learn on these rotations has no EM application, but learn what you can, and focus on translating that knowledge into the ER realm. Knowing your colleagues’ world will make you a better EM physician and improve your interactions with your consultants in the future. These rotations are primetime for networking. Be kind, work hard, play nice. This will serve you well throughout the rest of your residency and your career – especially in the military. Military medicine is a very small world. In your future career, you may work closely with many of these co-residents, consultants, and staff attendings in small hospitals and austere locations. So make friends, not enemies.

Be kind, work hard, play nice. This will serve you well throughout the rest of your residency and your career – especially in the military. Military medicine is a very small world.

Podcasts. Since EM requires a mastery of a vast breadth of knowledge, and since residency is so short, you should nearly always be studying. A great way to study passively is via podcasts. Our residency has many outside rotations, and you will often have lengthy commutes. Don’t waste this time. You should listen to EM podcasts during your drives, at least when your mind is fresh – on the drive into work. My mind was fried after most shifts, and instead of listening I found myself spacing during my drives home, so I stopped listening to educational podcasts after work. I consider passive learning from podcasts to be supplemental, and never a primary mode of studying since you are frequently distracted and never 100% focused. But podcasts add depth and breadth to your studying and to your awareness of what is going on in the EM world. It is also a great way to keep up on current practices.

Podcasts add depth and breadth to your studying and to your awareness of what is going on in the EM world.

Boards. Boards are weird, despite all of your studying and even if you are performing like a rockstar on shifts, you must still study specifically for boards, otherwise you will fail. The best way to study for the yearly ITE (Inservice Training Exam) is by practicing board style questions – and lots of them (more below). Oral boards are also their own entity, they are a game, and you must learn to play that game well (more below). Promotion boards – “promo boards” – are specific to our residency, and preparation should begin months ahead (more below).

Our NMCP ER resuscitation bay.

Procedures. The ACGME minimum requirements for procedure numbers are easily achievable. Only 30% can be completed in simulations, except for the extremely rare procedures – “pericardiocentesis, cardiac pacing, and cricothyrotomies.” Remember, these numbers are the absolute minimums. These numbers will never make you an expert, but they should at least make you competent. Procedures are also performed less frequently in the ER with the implementation of more conservative management approaches, so residents often struggle for procedures. Positive pressure ventilation saves many patients from intubation. This is great for the patients, but bad for training. So approach every procedure as a precious commodity. You should prepare outside of the ER and the procedure lab by reading Robert’s and Hedge’s, perusing website blogs, watching YouTube videos, and mastering the nuances of each procedure. This will maximize your learning curve. Also, our residency provides many procedural opportunities through simulations and cadaver lab. And with the internet and a vast array of resources, you should achieve competence and in some cases master these procedures by the end of residency. Watch the YouTube channels EMRAP HD and EMCRIT for awesome procedural education.

Variation. Everyone learns differently, the approaches described above will not work for all. But each resident must figure out how to implement a broad review of all EM content, while focusing on board specific and rotation specific study, and reviewing clinical questions encountered during each shift. Studying in residency is a balancing act, but you can do it. Focusing intensely and working hard during these few years of residency will pay dividends in your future career.

NMCP EM residents teaching Prolonged Field Care at Operation Gunpowder – a 3rd year medical student exercise at USUHS.

RESOURCES

Often, because our specialty is so broad, the art of EM is knowing where to find readily accessible resources. We must instinctively know resuscitation algorithms and emergency medication dosing, but many of the less emergent, less time sensitive, less frequently encountered diagnoses mandate quick referencing. Knowing and maintaining quality resources is essential.

TEXTS. While large textbooks are somewhat archaic, they still have their niche in learning EM. They provide the broad base of knowledge and the depth needed for the intimate study of a variety of subjects. They are not as handy for quick reference, but they do provide inclusive tables and spreadsheets that can be used as a reference if saved in a readily accessible format. But texts are best utilized when you are mentally fresh and have an extended period of time available, a large cup of coffee, and a firm couch.

  • Rosen’s is the gold standard Emergency Medicine text, and should be the EM residents’ foundational guidebook. It is very detailed and thorough, does not lend itself to quick reading, but provides a breadth of information about every pathology encountered in the Emergency Department.
  • Tintinalli’s is the runner up to Rosen’s. It is often more concise and an easier read than Rosen’s. Its tables, graphs, and pictures are phenomenal, and the bold words and phrases are helpful for scanning a topic if time is limited.
  • Robert’s and Hedge’s is the EM procedure text. I recommend reviewing the pertinent chapters before procedure labs, before or after procedures on shifts, and for learning all the nuances of those procedures.
  • EMRA minibooks. These are phenomenal little books (discounts and free books are available with an EMRA membership) with high yield information that can be used on shift or while quickly reviewing a case after shifts. I carried them in a small go-bag since we worked in a variety of ERs and I never knew which electronic resources would be available. I used the EMRA Antibiotic guide nearly every shift. EM Fundamentals is a concise review of the main EM pathologies, great to use during shifts as a EM1 or EM2, but especially helpful for a quick review after shifts. The EMRA EKG Guide is a basic, outlined format of all the main EKGs you need to know. While primarily aimed at junior residents, it also is great to review the specific definitions of each EKG abnormality. The Pressordex is a good resource for medication dosing if no electronic resource is available.
  • ECGs for the EM Physician 1 and 2 by Amal Mattu are phenomenal for review and learning the nuances of EKG reading. Buy the hard copies. The ekgs and official reads are separated by 30-40 pages, so I would read a few EKGs and then flip back to the official read for reference. These books are great for getting in the necessary reps to become adept at EKG interpretation.
  • The Resuscitation Crisis Manual by Scott Weingart is a new resource with phenomenal, high yield, bulleted, stepwise instructions on how to handle critically ill patients in the ER. The hard copy is wire bound and the pages are waterproof.
  • Emergency Medicine: A Focused Review of the Core Curriculum is just one review book, but Joel Schofer, one of our Navy Staff Attendings, played a significant role as the editor. There are a plethora of other similar review books. These can be used for high yield reviews of EM content in preparation for boards, or as an adjunct to formal studying.
Trauma scenario for brand new NMCP EM interns and EM2s returning from the fleet during intern orientation.

WEBSITES. The internet has revolutionized research and study habits. Most of us “younger” students are very comfortable with using websites as primary study resources. Just be judicious, the quality of these online resources varies widely and they are not necessarily vetted or peer reviewed. Many websites require subscriptions for their services, these can often be purchased at discounted prices as a resident. There are many FOAM (Free Open Access Medical) Educations sites that are phenomenal resources. Some can be used for rapid, on shift reference, and others present more lengthy, formal presentations of EM content. The FOAM world is rapidly expanding, but this can lend to one getting lost in a network of resources. Find a few trustworthy websites, use them frequently, then use Google for everything else. Below are a few resources that I found useful during residency:

  • emresportsmouth.org is our residency website, it is password protected, and it is the hub for information sharing designed specifically for the NMCP EM Residency. All of your academic resources, schedules, “go-by’s,” rotation gouge, lab resources, off-service contact information, combat medicine resources, AWLS resources, and various other residency specific resources are available here.
  • wikem.org is an excellent website for reference during shifts. Think of this site as the Wikipedia of EM, this may be where you start with your information gathering, but is not really considered a vetted source.
  • uptodate.com is a thorough, non-EM specific resource that can be utilized on shift for a variety of clinical questions, drug referencing, etc. It is accessible through most DOD medical facilities, and you can obtain a personal account via our NMCP librarians. Once you obtain your personal account, as long as you are logged in, you can obtain CME credits for articles that you read and reference.
  • emcrit.org is another phenomenal resource for the critical care that we deliver in the ER. In addition to the EMCRIT-RACC podcasts and articles, the website has expanded to include a variety of other contributors from various disciplines, but all specializing in resuscitation and critical care.
  • emrap.org is rapidly becoming “THE EM” online resource. It started with a monthly podcast but is constantly expanding and becoming a one-stop shop for all things EM. But you do need a membership to access the content. This can be obtained cheaply during residency via an AAEM/RSA membership.
  • emdocs.net is an EM-specific, FOAM website that contains many awesome articles, some of them authored by our very own residents and staff.
  • rebelem.com is great for journal club preparation. If you can find the article to be reviewed on this website, you will be golden. This website reviews much of the current EM literature and comments on the quality of the studies and the evidence. There are other comparable websites that can be utilized similarly.
  • ECGWeekly.com is another excellent option for learning EKGs. Dr. Amal Mattu – EKG guru – uploads one EKG every week and explains the nuances of the read, and the annual subscription is only $26. This is a great way to force yourself to improve your EKG reading skills regularly.
  • MCCareer.org is Joel Schofer’s website and should be considered the go-to resource for your Navy career development and advancement. His FITREP writing resources are invaluable.
  • kinnetikmedicine.org is my own website – shameless plug – with a focus on operational and resuscitation medicine. If you are interested in military dive medicine, operational courses, or wilderness medicine, then there are a variety of resources available, and the breadth is constantly expanding.
  • openathens.net is also a great resource. Get an account via our librarians, this will give you access to PUBMED articles offsite, and many textbooks via online format. This is a great resource if you are on an outside rotation or not able to access the content available through the hospital intranet.
Advanced Wildnerness Life Support Course in the Adirondacks.

APPS. Smartphone apps have also revolutionized the learning sphere. You can now have complete textbooks in the palm of your hand that are easily searchable and readily available at the swipe of a finger. Below are a few EM specific apps that I found helpful in residency:

  • PalmEM, ERres. PalmEM is easily my favorite EM app. It is organized by categories, but can be searched as well. It also has a “Pedi-tape” page – essentially the Broselow tape, which is essential for pediatric resuscitations. ERres is another great app that I used as a backup to PalmEM. If I couldn’t find it on PalmEM, I would then use ERres, but ERres is not as user friendly as PalmEM.
  • Pedi-STAT. This is another pediatrics apps option. Also organized like a Broselow tape, you can use this interchangeably with the PalmEM “Pedi-tape” page and choose whichever format you like best.
  • Uptodate. A great app from the awesome website. For those times when you don’t have uptodate access easily via the computer.
  • MDCalc, Qx Calculate, MedCalc. MDCalc should be the only calculator app you ever really need for EM, but I occasionally needed to use the other calculator apps on inpatient and ICU rotations. If you can’t find a specific formula on one, just search the other, one of them should have what you need.
  • Rosh Review. Awesome! Amazing app! The entirety of Rosh Review in the palm of your hand. This is great for doing questions on the bus, the train, the car, etc.. Fill those extra minutes with Rosh Review instead of social media.
  • SonoSupport and Pocket EUS are excellent emergency ultrasound resources especially for new learners. They show standard views, give technique recommendations, and important measurements and data points.
  • EMRAP. This app is constantly improving. There are so many more additions when compared to just a few years ago. It has all the EMRAP podcasts, along with the C3 content, EM Abstracts, LLSA article reviews, and Crunch Time EM. My only complaint was that it frequently logged out, requiring me to log in again to get back on the app (I know, knit-picky, but annoying when you are just trying to start an episode quickly while you are getting on the road).
  • Epic Haiku. This app was an excellent resource for the Sentara inpatient rotations (Trauma/ICU). You can access Epic from your phone, look up your patients, their notes, their labs, etc. This was clutch for rounds, some residents read their notes straight off their phone instead of printing out everything (which was awesome, especially if the printer was acting funky that morning). It was also great for lengthy rounds when you needed updated labs. The greatest feature of this app though is the picture adding function. You can take pictures of physical exam findings, or lacerations, or other injuries via the app then upload them directly into the EMR without the pics staying on your phone or violating HIPAA. You can attach those pics to the physical exam section of your note. Again, an incredible tool.
  • MilMed Apps. I didn’t use this app as much, but some of my co-residents did. It is specific to our hospital and contains the phone numbers to various specialties and departments. I’m not sure how reliable the information is or how frequently it is updated.
Chief resident teaching airway essentials to new NMCP EM interns.

PODCASTS. Podcasts are also an amazing addition to life and learning. These can be used in a variety of manners, I used them mostly for passive learning while driving. Often, podcasts have associated notes posted on the hosting websites that can be referenced later for additional learning or exploring their sources. There are so many podcasts now it is hard to keep track – toxicology, pediatrics, basic EM, critical care, operational medicine, etc. Below are the core EM podcasts that you should add to your listening library during and after residency.

  • EMRAP. Emergency Medicine Reviews and Perspectives was a monthly podcast created in 2001 by Dr. Mel Herbert. It has now expanded into a massive EMpire with many EM gurus contributing, and the offerings are constantly expanding. If you choose just one podcast source for residency, this would be a great choice, it literally has everything, and contains volumes of podcasts from previous years. During residency, you can access EMRAP cheaply via a yearly AAEM/RSA membership, after residency the price increases significantly. The core offering of EMRAP is the monthly 3-4 hour podcast divided into topical sections that are easily digestible in a short car ride. And they also publish associated pdf notes for each podcast that are phenomenal for reference.
  • EMCRIT. The free, non-subscription, EMCRIT podcast was created by Dr. Scott Weingart, an ED intensivist from New York. He is EM trained and completed a critical care fellowship at Baltimore’s Shock Trauma Center. EMCRIT is the premier EM critical care podcast, and is an excellent resource for residents and attendings wanting to refine their critical care skills. Attempt listening to most of these podcasts at some point during residency, I’ve listened to many of them multiple times. His website has also expanded significantly to include other contributors and topics – PulmCrit, EMNerd, The Tox & Hound – but the EMCRIT podcast, now labeled EMCRIT-RACC, remains the core offering. They are also in the process of building an Internet Book of Critical Care, which will eventually contain all things critical care online. He also recently published the Resuscitation Crisis Manual, which is available in pdf and hard copy, and is an awesome, high-yield resource that every EM physician should own.
  • ERCAST. This podcast is also one of my favorites, created by Dr. Rob Orman, EM physician. While he addresses purely medical themes, he often discusses the theory, the art, and the finer points of practicing EM. He recently made the podcast subscription based through Hippo Education, but he has left years of his initial podcasts freely available to the public on his original site linked above. These are golden, and you should make an attempt to at least browse and listen to much of them.
  • MCCareer.org. This podcast was created by Dr. Joel Schofer, USN EM physician, and addresses issues related to career advancement in the Navy medical corps. This podcast is great for naval officers in addition to perusing and using his related website.

YOUTUBE. YouTube rocks! I am a visual learner, and there are so many helpful resources on YouTube for medicine, and more videos are being added constantly. Subscribe to the EMRAP HD, Essentials of EM, and EMCRIT YouTube channels, and explore the available learning aids. I may or may not have watched a few YouTube videos on my computer before performing procedures in the ER. Also, lectures from the EM greats are occasionally posted on YouTube free of charge.

Casualty Collection Point at JEMX.

LEADERSHIP

Collaterals. Our residency is very much a resident run program, which can be intimidating at first, but this dynamic offers incredible leadership opportunities that mature and develop the NMCP residents far beyond their peers. During EM1 and EM2, you will generally be left alone to focus on learning, establish your practice patterns, and settle into EM. But, during EM3 and EM4, you are expected to assume leadership roles within the residency in addition to any positions that you may have electively assumed in the first two years. The primary fourth year collaterals are Chief Resident, SIM, Lab, Intern Coordinator, Medical Student Coordinator, Research, Journal Club, and PIPS (our M&M). The third year collateral positions are often assistants to the fourth years. The specific responsibilities of each collateral varies yearly, but each collateral invariably demands significant effort and consumes a measurable portion of your time. I encourage you to embrace your collateral, this is where you can have an immediate and lasting impact in your own residency program. I also encourage you to create a “go-by” or a concise turnover file for those who come behind you. Also, provide a thorough turnover to your successors to ensure that your efforts are not lost, and that the residency continues to improve each year. Bloom where you are planted, leave your collateral in a better condition than what you inherited.

More trauma scenarios at the end of residency final exercise.

Lectures. During residency, you will be responsible for delivering lectures to your peers. The requirements are constantly changing, but as an intern you will give 1-2 lectures, and as a fourth year you will give 4-6 lectures. These range from short, mini-topics to longer, thirty minute lectures. You are expected to study and research your topic to the point of being a subject matter expert, but this is often not the case. Unfortunately, many residents wait until the last minute to begin preparing. This is unprofessional and a disservice to your fellow residents and to yourself. The chiefs will disseminate the academic calendar at the beginning of the year which details the block schedule, the topic of each block, and the block when each resident is required to lecture. Review this calendar and the block topic for your lectures, then plan accordingly. Often, you will encounter an interesting patient or case over the coming months that meets your topic needs making your lecture preparation much easier.

Study and research your topic to the point of being a subject matter expert.

Also, begin focused preparation AT LEAST one month ahead of your lecture. During your lecture, present the core knowledge, the supporting evidence, and any newly available research. I attempted to present topics simply, and to leave the audience with just a few main memorable points. Improving your lecture preparation and delivery during residency is vital to your future success as a staff physician. Most physicians, especially those with a future in academia, will lecture numerous times throughout their careers, so prepare well. Residency is the perfect place to practice in a relatively safe environment with your peers and staff physicians in attendance. You will receive real time comments and recommendations, and also lecture reviews afterward. Use this advice to improve your performance.

Lecture time!

BUSYWORK

As if learning medicine during residency isn’t difficult enough, you also must complete a ton of administrative work. Most often, this seems to distract from the true purpose of residency, but it must be done, and you must learn to balance your time accordingly.

Life Organization. The best decision you can make for your professional life is to establish an organizational process early. There are many different products and approaches, but you must find what works for you. Some use books, hard copy calendars, organizers, etc., but I use electronic resources accessible from my Iphone since that was always on my person. Google products work perfect for my organizational needs – they are interconnected, user friendly, and free. I use Google calendar for recurring events, new events, and my shift schedules. Most shift scheduling software (including Amion) can sync automatically with your google calendar, this is a huge time-saver. I also use Gmail – it’s free, works great, is user friendly and easily searchable. You can’t automatically forward your DOD email, but you can individually forward important emails to your Gmail account, just label them accordingly in the email body or subject line so you can find it easily later. Google Drive is awesome for storing professional certificates, important articles, etc. Unfortunately, the .mil firewall does not allow you to access Google Drive from a DOD computer, so you may need to use your Gmail to supplement Drive. Google Docs and Google Sheets are also useful tools, but they are blocked on DOD computers. Google Keep and Google Tasks are great “to-do” list applications. Google Tasks allows you to set completion dates and it syncs with your google calendar, so I put all my license/merit badge expiration dates and big projects here. Tasks appear on my calendar, send notifications when due, and can be reviewed in list form on the app. Google Keep is great for simple task lists, grocery lists, etc. You can manage multiple lists, store pics or files, and check them off when complete. If you use Google Chrome, Gmail will automatically open a sidebar with Google Tasks, Keep, and Calendar readily available for referencing and editing. I also use Apple Notes for annual goal sheets and note taking. There are many different organizational tools available, but these are what I found helpful. Whatever you do, you must choose a system that allows you to stay organized, otherwise you will be mired in admin woes and forget many of the important events and tasks discussed below.

The best decision you can make for your professional life is to establish an organizational process early.

Research. Our residency program requires significant research involvement and the completion of scholarly activities to graduate. Fortunately, our research programs are incredibly robust. We are home to the Combat Trauma Research Group which is constantly producing new data and publications geared towards improving the safety and survivability of our warfighters down range. Residents at all levels frequently present posters, publish articles, and win national research awards regularly – including most recently Dr. Eric Sulava being named the 2018 ACEP Resident Researcher of the Year. So get involved early, find a staff mentor, and enjoy the opportunities to improve your world.

Physician License. You must maintain a current physician’s license during training and renew before expiration, or risk professional repercussions. I chose to license in Virginia, the state license is inexpensive and easy to maintain and renew online. Some may choose to license in their home state or in their eventual practice location, but ensure that you adequately research the requirements and the cost, it may save you future grief.

Exploring the inside of a C-130 rigged for patient transport.

Merit Badges. ACLS/ATLS/PALS/BLS are the main merit badges. NRP is great to have, although not required everywhere. Make sure that you keep these current, it is ultimately your responsibility. The residency “Program Management Specialist” (AKA Mom) will help you with these and remind you when they are due. She will also forward your certifications to the outside hospitals for upcoming rotations, but you must remain up-to-date or risk rejection from the rotation. Schedule renewal courses far ahead of time, some are infrequently offered at NMCP, and the course dates may conflict with your other residency responsibilities.

DEA number. You must also maintain a DEA license as a resident physician. It lasts three years, so if you apply as an EM2 and go straight through, you will not have to renew during residency. But, if your training experience is prolonged and circuitous like mine, then you must renew during residency. As a DOD physician, you are exempted from the application fee ($731 a few years ago). Don’t let your DEA license expire, or you will have problems prescribing controlled substances during outside rotations.

New EM interns learning TCCC on the fly.

New Innovations. During residency, you must log your work hours, lab hours, academics, and any procedures. Below are a few tips.

  • New Innovations is the logging website that our residency utilizes.
  • Log regularly, ideally after shifts, or at least weekly. Or if you get behind, log AT LEAST every few months.
  • Keep track of good cases/procedures. Some residents use books and patient stickers, but be careful, this is PII. Never lose or misplace that book.
  • Review the “loggable” procedures in New Innovations occasionally to remind yourself of the procedures you should be logging, and to jog your memory about cases you may have forgotten.
  • You will perform sufficient procedures during residency to meet the minimum requirements per ACGME, but you should aim to surpass this significantly. Keep logging. These numbers will count after residency as well.
  • Log labs, log Cadaver, log Simulations, etc. These will count (but only 30%), max them out, especially with the very rare procedures.
  • You can also log cases and procedures that you supervised for junior residents and medical students.
The incredible Appalachian Trail. A moment of peace.

Relias (formerly Swank, formerly NKO…). Military online training will prove to be the bane of your existence. Yes, most of these training modules are ridiculous, but they must be completed to keep the residency leadership from sending you annoying emails. While this may be the least of your personal worries, if you are constantly delinquent on Relias, your leadership will notice and there will be consequences. Pro tip – google that specific training module, you may find random websites with helpful information…

PHA/BCA/PRT/Dental/Urinalysis. You are a resident, but you are also a naval officer. And the Navy must maintain its medical readiness. Ensure that you complete your annual PHA, and remain at least a Category 2 on your dental record. As a naval officer, you should maintain some level of physical fitness during residency, which can be difficult, but it can be done with discipline and prioritization. The BCA/PRT cycle occurs twice a year in the spring and the fall. Great news! If you score excellent on your PRT now, you are only required to complete one PRT per year. And scoring excellent on the PRT is not too difficult, even while only maintaining an average fitness level. Randomly, you will be selected for a urinalysis, but “Mom” will remind you if you are in the hospital, or cover for you if you are away. Don’t forget the urinalysis if you are present, however inconvenient. Fulfill your patriotic duties and “pee for your country.”

NMCP EM Class of 2019 Graduation aboard the USS Wisonsin.

BOARDS

Written Boards. ABEM offers an Inservice Training Exam (ITE) annually for EM residents during the last week of February, typically on a Wednesday. The ITE is closely representative of the written board that must be completed after residency to obtain board certification. The ITE is standardized nationwide, and is a great tool for each resident and program director to gauge how well their preparation for written boards is progressing. Do not dismiss this test. The ITE itself does not officially mean anything professionally, but it is a litmus test. If you perform poorly, your residency leadership may require you to participate in remediation and extra study sessions. If you perform well, they will leave you alone. While scoring well on the ITE does not necessarily correlate with shift performance, it is a necessary step you must take, and you must pass your written boards eventually after graduation.

The ITE itself does not officially mean anything professionally, but it is a litmus test.

Our residency program provides a Rosh Review subscription with approximately 1300 practice questions, and also purchases a simulated ITE exam each year. This is an incredible resource, do not waste it. Each year, I completed most of the available practice questions before the ITE. Start AT LEAST a few months before the ITE and set a goal to complete a certain number of questions per day or per week. I found that studying in tutor mode worked best for me. In this mode, you answer a question and then get immediate feedback via the answer and a concisely crafted explanation. You progress more slowly through questions this way, but it works by providing immediate learning and feedback. Question banks are great study tools because of the active learning involved. Answering well crafted questions recruits additional brainpower and cements pertinent facts more completely. Rosh Review maintains a mobile app, so you can easily study when only moments are available – while resting, while waiting for an appointment, or while sitting on the toilet, etc. With purposeful effort, you will rock your inservice. Other residents choose to study board review books as well, or complete additional question banks. Find what works for you. Our residency website contains multiple resources, also below are a few extra resources:

  • Comprehensive Rapid Board Review. This podcast (with slides) is available via the linked website and also via Itunes under the Emergency Board Review show. It is one hour and 43 minutes, but is super high yield. I usually watch this a few times during the last week before boards. It will help you remember multiple simple recall questions on the exam.
  • Emergency Board Review. This Itunes channel has multiple other board review podcasts. Some are helpful, others not so much. But they are free, and can be digested passively while driving or performing other duties.
  • EMRAP Crunch Time: If you have an EMRAP subscription, this is a phenomenal resource. These are EMRAP’s high yield podcasts for each board topic.
NMCP EM Residents working the Ambuscope

Oral Boards. After graduation, you must also pass oral boards to become board certified. To prepare us adequately, our residency hosts Mock Oral Boards multiple times per year in place of conference. These are great opportunities to learn more about this exam. Oral boards are essentially a game, and you must learn to play that game well. During these sessions, you will learn how to prepare and organize your thoughts. Some residents write prompts on the provided scrap paper, or follow a systematized approach to each vignette. The mock oral boards allow you to practice, modify, and solidify your system. Below are a few helpful documents with exam tips from our staff.

NMCP EM Resident presenting research.

Promotion Boards. Promotion boards are military specific. For our program, your promotion board will occur before you progress to the next year group. This annual board lasts one hour, during which you will sit in your Service Dress Blues across from three staff attendings while they question you on a variety of specific topics that you are required to master at that point in your training. You MUST study specifically for this board, you can flail or shine, you choose. There are many different resources, some residents create their own tools, others use what is already available. This board requires rote memorization, which takes time. So don’t procrastinate. My poor wife was often my study partner. She would randomly question me on the testable topics, and I would reply in as much of a cogent manner as possible. Do this at least a few times with other residents, or someone who loves you very much. You can often recall these facts in your head, but things fall apart when you are forced to verbalize your thoughts. Don’t fall apart in front of the board. There are multiple resources available on our residency website. Below is the list of required topics from a year ago, which should be similar to the current list of topics.

The PGY-2 page is missing from this Primer, but for this year you must demonstrate proficiency in all 27 procedures detailed in our EM procedure manual which is available on the residency website. The PGY-2 board is different from the other promotion boards in that it is conducted in the procedure lab.

NMCP EM interns and EM2s practicing TCCC on the beach.

WELLNESS

Graduating from emergency medicine residency is a career milestone, but if you leave a pile of emotional baggage, a broken family, and rampant discontentment in your wake, then is it worth it? Thankfully, our EM leadership has recognized wellness as vital to resiliency and career success, and has invested significant effort and emphasis into improving our community’s wellness collectively and individually. According to ACEP’s free publication – Being Well in Emergency Medicine: ACEP’s Guide to Investing in Yourself – “wellness” is defined as “a state of complete physical, mental, and social well-being.” This guide is a thorough 128 pages, so it really gets into the weeds with some topics, but overall it is a great resource that should at least be perused during residency and digested in whole later. Below are some of my simple thoughts and practices that allowed me to survive and thrive in residency.

NMCP EM resident community service wellness activity.

My Story. A few years ago, I heard incredibly impactful words of wisdom regarding time management in residency while watching a YouTube video interview of a Crossfit Games athlete – I know, lame. When talking about her life, Crossfit, and her pursuit of Medicine (currently a Family Medicine resident), Julie Foucher referenced the Oprah Winfrey quote, “You can have it all. Just not all at once.” Another similar quote echoes, “You can do anything, but not everything.” At that time, I was about to return to residency, I had accumulated a plethora of interests and hobbies, I had many life and career goals, and I was married with four kiddos to support and entertain. The Oprah Winfrey quote hit home. We live in America, the land of freedom and opportunity. If your imagination and work ethic are epic, you can do anything. But you can’t have everything at once, especially during residency.

You can have it all. Just not all at once.

Oprah Winfrey

During residency, you must suspend many of your interests, hobbies, spare time, time with family, time alone, etc. to merely survive and graduate. So, I deeply evaluated my priorities, and established a general guideline for how I would focus my time during the next few years of training. I finished with a list of alliterated words that all started with the letter “F.” These priorities are incidentally somewhat similar to the ACEP’s Seven Spokes of the Wellness Wheel. Residency is without explanation the most important aspect and the centerpiece of these few years, so if you have not already done so, review all of the information above to succeed in this area. So outside of the above information, how did I survive and thrive in residency? What is the glue that held me together?

McAfee Knob on the Appalachian trail during a Backpacking Medicine Course.

Family. The most important people to me in the world are my family. It seemed pointless to me to succeed in residency but fail as a husband and father. Thankfully, my wife is awesome, very independent, self-motivated and adventurous, so the family continued life with or without me. Some months are better for family life than others. During many of the inpatient months, you will leave in the morning long before the family is awake, and arrive home late at night exhausted and fall asleep on the couch, only to repeat this cycle over and over again. And your few days off are spent merely recovering, catching up on sleep and admin work, and prepping for the next day. Other months are great – electives, selectives, toxicology, ER months – purpose to spend more quality and quantity time with your family then. It seemed there was always a project brewing, or a task to complete, or a test or board to study for, but sometimes, you just need to set those things aside and play with your kids, or watch a TV show while drinking a glass of wine with your spouse/SO. Make sure that you also schedule specific vacation time each year and do something that the family loves – Disney, camping, beach outings, etc. Maximize your allowed vacation time away from the residency every year, you and your family need this.

You can do anything, but not everything.

Avoid bringing work home, or at least avoid bringing the stress of work home. Some have a specific time period of decompression before they drive home, I never established a personal rule, but maybe I should have. Occasionally, if I did not decompress after an especially difficult shift, I found myself impatient and short-tempered with my children when they acted like children, which is asinine, right? It seemed that I gave all of my good energy to the residency, and the family just got the left-overs. It took me a while to figure this out, but recognizing this as an issue is important. So whether you listen to a non-medical podcast on the drive, or wait an hour before heading home, or spend some time meditating, or workout in the gym first, whatever works for you, figure that out. Also, despite their ultimate importance, you occasionally need alone time away from the family for your own resiliency. Hopefully your family or significant other is as understanding as mine.

Family hike at Tarzan Falls in Guam.

Faith. I’m a Christian, and participated as much as able with my church during residency, which unfortunately was not much due to the busy residency schedule. Occasionally, I played guitar in the worship band, which was a nice creative release and a time to spend with other fellow believers. Whatever your faith may be, or whatever centers you, make sure that you maintain that to some degree for your own spiritual health. This will ultimately make you a better and more balanced physician, and will free you to invest yourself into your professional purpose and into your patients.

The kiddos touring the USNS Comfort.

Friends. During residency, you will bond with others in your profession in a way that may never occur again to that magnitude in your professional life. Enjoy it. Enduring adversity with a group of likeminded individuals creates a brother/sister-hood that is not easily broken. Pizza and beer while laughing and complaining with fellow residents after long week is emotionally therapeutic and also normalizing. Occasionally, residents hosted house parties that I believe contributed significantly to the robust morale and teamwork of our residency program. Of course we all had our low points, and you will likely have a low point at some point during residency, this is normal. But providing a listening ear and a gentle hug are often enough to encourage each other and lift each other up. Our residency program also provides many official opportunities to get together, enjoy life, and decompress – Journal Clubs, Christmas Parties, the annual Kangaroo Court and Graduation Party, the Summer Welcome Party, and various other similar activities. Enjoy these protected moments away from the craziness of residency, and when able, spend time with your friends.

NMCP EM Residents ready to rock in “Casualty Receiving” (CASREC) during the USNS Comfort Exercise (COMFEX).

Fitness. It is my personal belief that we as physicians should model to our patients the ideal image of physical and mental health. Many of the diseases that we encounter daily are a result of poor life choices – the consequence of unrestrained, undisciplined living and the ravages of the metabolic syndrome. Physical fitness combined with a relatively healthy diet would prevent much of the first world health problems that pervade our health care system. As naval officers, it is especially important to maintain some level of fitness, our bodies are the engine and the tool through which we accomplish our responsibilities. Someday, our patients, our service members, may rely on our health and fitness for their survival. I’m not advocating that you maintain athlete level fitness during residency, but do something, hopefully regularly.

Many of the diseases that we encounter daily are a result of poor life choices – the consequence of unrestrained, undisciplined living and the ravages of the metabolic syndrome.

Before residency, I set a goal to work out at least every 3-4 days on average, and I met that goal despite being a husband, father, home-owner, and chief resident. If I can do it, you can too. Whether you run, swim, bike, lift, or physically exert yourself in some other fashion, just get after it. I’ll admit, often I did not feel like working out, but just starting a work out was all I needed. It became so much easier after that. Building my own small home gym helped tremendously. Despite limited time, I could walk out to my garage and started lifting. The greatest thing about having a home gym was that I didn’t have to leave my home to work out. Often my kids would “work-out” with me, and my wife would join as well. So we spent time together as a family, it was a much more efficient option than driving to a gym, and it established good habits and a healthy mindset for my family as well. The gym cleared frustrations and reset my mind, provided a sense of accomplishment outside of medicine, improved my mental toughness and stress modulation during shifts, and just helped me feel better over all. So just get after it. You can do it.

Get after it!

Fun. If you have too many interests and hobbies like me, these need to be sacrificed during residency due to the limited time and the importance of the other variables. But don’t eliminate them completely, you need something to pursue outside of medicine that brings you meaning and satisfaction. Whether you occasionally hunt, fish, climb, ski, snowboard, home brew, shoot, dive, run, swim, lift, read, travel, etc. Of course, this will be in a limited fashion, but it will make you a much more balanced and fulfilled emergency medicine physician. I chose to invest my extracurricular “fun time” in physical fitness and the occasional wilderness medicine pursuits, and nearly fulfilled the requirements for my FAWM (Fellowship of the Academy of Wilderness Medicine). We need an outlet. Those who only “do medicine,” often don’t last long in the emergency department. Creating occasional time during residency for fun pursuits will establish healthy career habits that should continue after residency.

A couple that plays together, stays together.

Food. During busy ER shifts, I quickly realized that I had to eat or my brain just hit a wall. As a junior resident, I didn’t prioritize eating and near the end of shifts I found it hard to think, I experienced headaches, and I felt physically weak. No matter how busy the ER becomes, your brain needs glucose. My routine became: eat a good meal before each shift, drink a cup of coffee during the first few hours, and then down a zero calorie “White Monster” (caffeine bolus) and eat a quick lunch halfway through the shift. I also ate snacks throughout the shift – jerky, fruit, granola, etc., and drank multiple Nalgenes of water to stay hydrated. You and your patients need you at your best, your brain needs fuel, so figure out a system that works for you. But you need to eat.

ACEPnow for the win.

Finances. The last thing you need to stress about during residency is your finances. Don’t be tempted to buy the big house or to over-extend yourself financially in other ways. Residency is temporary, and the work of residency should be the main source of your stress, not wondering how you are going to pay your bills. A great resource for physicians is the White Coat Investor. Dr. Jim Dahle is an EM physician who established the White Coat Investor website to “help those who wear the white coat get a fair shake on Wall Street.” He now hosts a blog on his website, a podcast with a plethora of great information, and he has also written multiple books – The White Coat Investor, Financial Boot Camp. Both of these books contain great advice, thankfully we had fulfilled a lot of his recommendations already, and now that residency is complete we are investing much more effort into living financially responsible. Appropriately, Dr. Dahle’s advice is tailored for physicians, and he occasionally offers advice for military physicians in his books and podcasts (he was a former Air Force MD). Dr. Joel Schofer, one of our own Navy attendings, also gives excellent financial advice on his blog and podcast MCCareer.org. He was featured in the White Coat Investor Podcast #92 “Being a Military Doctor,” and contributes regularly to AAEM’s Common Sense regarding physician specific financial concerns. Being squared away financially will erase much unnecessary stress and will allow you to focus on what truly matters during residency.

One of the many beautiful panoramic views on the Appalachian Trail.

The Light at the End of the Tunnel

Remember, residency is a finite period, so make the most of it! Study hard and prepare diligently for the rest of your career during these few years. Make sure though that you incorporate life habits that will help you survive and succeed in residency and beyond. A word of encouragement…staff life is awesome! Just keep on crushing residency, and get after it!

NMCP EM Class of 2019.

-Brad Kinney MD. Special thanks to Dr. Katherine Biggs, my co-chief, and Aimee Kinney, my wife, for editing and providing suggestions to improve this post.

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