CONCEPTS, COMPONENTS & CONFIGURATIONS residency, emergency medicine

An Applicant's Evaluation of an Emergency Medicine Internship and Residency Applicants to emergency medicine residencies face an increasingly difficult task of evaluating a greater number of training programs. High-quality information must be obtained by applicants prior to their submission of a ranking list to the National Intern and Residency Matching Program. Resources to assist applicants in this task have been limited; personal interviews are critical in this process. In the relatively new specialty of emergency medicine, medical students may fail to obtain optimal information during interviews. A list of suggested interview questions is provided. Judicious use of appropriate questions can help applicants obtain the proper information. Residency program directors and staff may also use these questions to assist applicants. [Koscove EM: An applicant's evaluation of an emergency medicine internship and residency. Ann Emerg Med July 1990;19:774-780.] INTRODUCTION The first residency training program in emergency medicine was started in 1970, and the number of programs has increased steadily since that time. Prospective emergency medicine residents are therefore faced with an increasingly difficult task of selecting the residency of their choice. The computerization of the selection process through the National Intern and Resident Matching Program has minimized some difficulties. Despite the assistance of a computer, each applicant must still decide what programs to place on the match list and in what order. While these crucial decisions are often based on highly subjective and personal criteria, it is in the best interest of both the applicants and their future programs that the applicants obtain as much information as possible prior to this major commitment. The material presented here will assist the applicant in obtaining this information. It will also assist residency program directors and staff in providing this information to the applicant. Most emergency medicine residencies provide applicants with written information about their programs. Unfortunately this material may be quite inadequate, lacking in breadth or depth of information. Written material also does not provide the subjective "feel" of a program. Therefore, only by assessing a residency in person can an applicant obtain the appropriate information to assist in the final ranking task. The resources to assist prospective applicants in this task have been limited. A pamphlet of advice and recommended interview questions for a "generic" specialty has been prepared by the American Medical Student Association. 1 A detailed text for "getting into residencies" has also been published. 2 While these resources are helpful, medical students may be unaware of them or find that they do not entirely meet their needs, particularly for the specialty of emergency medicine. Almost 15 years ago a similar resource with the same limitations was written specifically for applicants to internal medicine residencies. 3 Because emergency medicine is one of the newest medical specialties, with several unique aspects, it is not surprising that applicants to emergency medicine residencies may frequently fail to obtain the optimal type and amount of information during their interviews. Applicants may ask certain interview questions based on their experiences in individual emergency medicine rotations. However, given the unique character of each program, these questions may be unin-

19:7 July 1990

Annals of Emergency Medicine

Eric M Koscove, MD Los Angeles, California From the Department of Emergency Medicine, Los Angeles County-University of Southern California Medical Center, Los Angeles. Received for publication June 15, 1989. Revision received August 30, 1989. Accepted for publication October 26, 1989. Address for reprints: Eric M Koscove, MD, Department of Emergency Medicine, LACUSC Medical Center, 1200 North State Street, Los Angeles, California 90033.



t e n t i o n a l l y biased or u n d u l y proscribed by the parochial nature of a single rotation. The only additional resource m a y be the medical student's advisor, who may be an invaluable source of information or, conversely, may be unable to provide adequate assistance, particularly if trained in a field other than emergency medicine. The applicant thus enters interviews with a " m e n t a l guidebook" of too few pages. To address these problems, the following list of suggested questions has been written for prospective applicants to emergency medicine residencies. Many questions are unique to emergency medicine, while in a few areas these closely parallel those previously applied to internal medicine. 3 While the list appears exhaustive, it is not meant to be used either in its entirety during an individual interview or verbatim. Within each category, more important questions have been italicized. Without lengthy experience in the field, medical students may not understand why some questions have been listed. Therefore, in selected areas rationales are provided in brackets. In a few instances, editorial advice is added. Some q u e s t i o n s are m o r e appropriately asked of a faculty member, while others are best asked of a resident or intern in the program. Additional c o n s u l t a t i o n and review of this list with a medical school advisor may be helpful. A l t h o u g h some applicants may find several questions, as worded, inappropriate in a particular interview, most of their themes should nevertheless be ascertained sometime during the interview day. Failure to obtain a critical evaluation of a program can result, at worst, in matching into a program that the resident finds undesirable. The interview day provides a golden o p p o r t u n i t y for b o t h a p p l i c a n t and p r o g r a m and should be used to its fullest. Applicants should remember that the interviewers provided to them by the program may not be entirely representative. It may be important to seek out any negative opinions to obtain a more balanced view. One way to obtain additional information is to request to observe in the emergency department at the end of the interview day and talk with unselected personnel. Another valuable source can be a resident in the program who 76/775

graduated from the prospective applicant's medical school. The questions listed can not only give applicants a resource for their interviews but can also provide residency program directors and staff with a series of inquiries that they should be prepared to answer. In addition, programs may elect to incorporate answers to some questions in the written material sent to applicants. In the future, uniform questions could be answered by all programs and placed in an annually updated central data base. Finally, as with all fields of medicine, emergency medicine is an evolving specialty, and these questions may require periodic revision to reflect future changes in the specialty and residency training.

OVERVIEW What is the structure of the internship and residency? How m a n y months will I be in the ED during each year? What other services will I rotate through and how long will I spend on each service? How m a n y and what kind of hospitals are in the program? Where are they located? Are any major changes imminent or planned in the hospital(s), rotations, or residency program in general? If so why? E D U C A T I O N A L ASPECTS

Curriculum Describe the educational program of the internship and residency. Is there a formal curriculum? How closely does the Department of Emergency Medicine adhere to the curriculum? Does the residency provide educational objectives for each of the block rotations? Where and how do the interns and residents learn the practice of medicine? Who does most of the bedside teaching of the emergency medicine residents? Does the program have a "slant," eg, " h a n d s - o n p r a c t i c a l " experience versus " h a n d s - o f f a c a d e m i c " approach? If yes, are the residents happy with it? Are there any plans to change that slant ? Does the residency have any educational features that are unusual or Annals of Emergency Medicine

notable, eg, hyperbaric medicine, toxicology, aeromedical prehospital experiences, international emergency m e d i c i n e rotations, exchange programs, occupational medicine, etc? Are the residents given any role in educational, administrative, or policy decisions made in their residency?

Didactics Where and h o w do the house officers receive didactic instruction? How often are conferences and lectures given? Who gives them? Are residents expected to give lectures or conference presentations? Are the conferences valuable? Is there enough free time to attend lectures? Are there conjoint conferences between different departments, programs, or institutions? Do the lectures tend to have a slant toward either clinical practice or "pure academics"? Are there any m a j o r p r o b l e m s or changes expected with the lectures?

Electives How much time do I have for electives? What are some of the electives available and where are they located? How difficult is it to get the electives of m y choice?

Educational Support What written, audiovisual, or computer materials, eg, core curriculum material, lecture handouts, journal articles, reading lists, videotapes, software, etc, are routinely provided and/or required? What is their quality and educational value? Are computer access and/or instruction available? Is there a library in the ED or hospital? How accessible is it? Is the library's collection adequate? Is computer searching of the medical literature available? Who pays for it? Are photocopying facilities available? Who pays for the copies? Is a journal club given? How is it run and is it educationally valuable?

Evaluation How are the residents evaluated? Are the evaluations worthwhile? Are written exams given? 19:7 July 1990

Is the American Board of Emergency Medicine (ABEM) in-service exam (a • ; test given to residents during their residency) mandatory, and if so, is a certain level of test performance required for advancement in the resi; dency? What preparation does the program , provide residents for part 2 of the ABEM board examination (an oral examination taken after passing the part 1 written exam)?



Does the program have an affiliation with a medical school? Is this affiliation "perfunctory" or meaningful? Who are the faculty? W h a t is their training and background? H o w m a n y trained in this residency ("inbreeding")? H o w "good" are the faculty? Describe their teaching abilities, accessibility, approachability, quality of medical care rendered, and lecturing and research abilities. What is the role of the attending physicians? H o w much primary patient care do they render? Does their primary patient care interfere excessively with their teaching? Are they away excessively from the Department of Emergency Medicine because of a d m i n i s t r a t i v e or research activities? Are there any m a j o r changes expected, eg, n e w chairman, n e w residency director? Have there been losses of faculty and if so why? Are there any faculty expected to leave in the near future? What is the morale and esprit de corps of the faculty? What are the c h a i r m a n and residency director like? W h a t are their b a c k g r o u n d s and training? What are their roles in the program/ division/department/institution/ medical school/community, etc? How supportive and approachable is the residency director? How are the residents treated by the director and the staff? Are any of the faculty known locally, nationally, or internationally, and if so, why? Do the residents have m u c h opport u n i t y to i n t e r a c t w i t h t h e s e 19:7 July 1990

"known" faculty?

GENERAL CHARACTERISTICS, BACKGROUND, REPUTATION Is the program known for any particular characteristic? Is the program in the forefront in a particular area of emergency medicine? H o w long has the program been in existence? [ N e w e r p r o g r a m s m a y have more problems than older ones because the latter may have had several years to improve.] What is its accreditation status? [All residencies in the United States must be accredited by the Accreditation Council on Graduate Medical Education. Various types of accreditation can be given, eg, full accreditation, provisional accreditation, or placed on probation for deficiencies. To sit for the ABEM e x a m i n a t i o n (to become board certified) a resident must have successfully completed an approved, ie, accredited, residency. A residency program m a y lose its acc r e d i t a t i o n during the r e s i d e n t s ' training, thereby p r e v e n t i n g t h e m from sitting for the examination.] Are there any expected changes in this status? Has the program ever been put on probation and if so, when and why? [Some of the following questions may only rarely be appropriate.] What is the relationship of the program/division/department to the rest of the institution? H o w supportive is the institution, medical school, community? Who are the house officers here currently? What do you think of your fellow residents? H o w "good" are the emergency medicine residents? What are their strengths and weaknesses? Where were they trained? What was their medical school class standing, and how many are AOA? H o w m a n y of the entering residents had previous training in other specialties? How far down on its match list did the program go to get its residents? H o w far down on the residents' list was the program? What kind of residents does the program want to graduate? What kind of residents fit in well in the program? Annals of Emergency Medicine

Are any other programs in the hospital having difficulty filling their residency slots and, if so, why? ]Other programs and their residents will play a role in the emergency medicine residenPs education.] What is the overall reputation of the program ? What is your impression of the medical care rendered by the ED? Would you send your own family member for medical care to your ED? If not, w h y not? [The latter questions, while highly incisive, are also potentially very inflammatory and, if broached, must be done so with delicacy.]

FUTURE OF THE PROGRAM What are the goals and plans for the department? Are any major changes planned? What will reaBstically occur in the next three to four years?

CLINICAL ASPECTS WITHIN THE ED Milieu How long are the shifts? H o w are the shifts typically scheduled: how m a n y days, evenings, and nights on, and h o w m a n y off? H o w m a n y patients are t y p i c a l l y seen by a resident in each hour or shift? Describe a typical day. How "hard" do you have to work? How do you usually feel at the end of a shift? How much "scut" work does the intern or resident perform? Who t y p i c a l l y starts IV l i n e s or draws blood? Who does the clerical work? What is the level of nursing and ancillary care support? Is it adequate? [Overemphasis on the working conditions by the applicant m a y be viewed negatively by some r e s i d e n c i e s and s h o u l d o n l y be broached lightly.] Does the ED have a "holding area" or o b s e r v a t i o n area for patients, and does this provide a valuable educational experience? How good are the laboratory and radiographic services? Is the laboratory computerized? How difficult is it to obtain old medical records?

ED Personnel How m a n y emergency medicine residents staff the ED? 776/77


Who else works there? Are medical students typically present? Who is responsible for teaching and supervising medical students and interns? How "good" are the nurses? What is it like working with them? What is the relationship between the residents and the nurses and other staff, eg, radiograph and EGG technicians, etc?

Patient Population Approximately w h a t percentage of the patients seen are admitted? What is their age distribution, and is there a p r e d o m i n a n c e of one age group? What are their socioeconomic, ethnic, racial, and sexual mixture? Do the patients have a broad variety of illnesses with varying presentations? Is there a predominance or lack of any type of pathologic process, eg, trauma, alcoholism, e m p h y s e m a , AIDS? Are the residents exposed to an adequate number of pediatric patients? Are the senior residents adept at recognizing a "truly sick" infant? Do the g r a d u a t i n g r e s i d e n t s feel comfortable taking care of all pediatric emergencies?

Admissions [A major role of the emergency physician is to decide whether a .patient requires admission to the hospital. This decision is frequently made in the absence of other physicians, eg, at night. This decision is often then communicated to the actual admitting physician, eg, an internist or pediatrician, in the form of a "recomm e n d a t i o n . " To develop this skill, the e m e r g e n c y m e d i c i n e resident should ideally be in an environment in which Re gradually assumes the position of solely determining the answer to this fundamental question of admission. A resident may not be given the appropriate amount of autonomy and may rarely be allowed to "make the final decision" to admit. In these cases, the decision to admit may in fact always be made by a resident from another service, eg, internal medicine or surgery. Without the a u t o n o m y to independently determine the admission of patients, the resident m a y not be able to fully develop the judgment necessary for fu78/777

ture clinical practice.] Who usually makes the decision to admit or not admit a patient? H o w much autonomy does the ED have in patient admissions? Who has final authority concerning patient admissions? Have the graduating residents developed the appropriate level of skill for deciding patient admission? H o w often do admission disputes (eg, b e t w e e n the D e p a r t m e n t of Emergency Medicine and another service) arise and h o w are they resolved?

Trauma [In certain locales, trauma victims are transported only to selected hospitals that are designated trauma centers with various levels of available service.] Is the program located at a "trauma center" ? If so, what level of trauma center? [Emergency physicians are expected to provide initial m a n a g e m e n t of trauma victims. To develop the appropriate skills, emergency medicine residents m u s t be given the opportunity to progressively assume increasing levels of responsibility for trauma victims, culminating ideally in total direct responsibility for initial management. These patients also frequently require the services of a surgeon. However, if the emergency medicine resident routinely assumes only a peripheral or secondary role of responsibility w h i l e the surgeon is u n i f o r m l y the single p h y s i c i a n in charge, the resident may not acquire the skills necessary for future clinical practice.[ How are trauma victims handled in the ED, eg, is there a trauma team? What is the role of the emergency medicine resident in trauma care or on the team? Who is actually in charge of the trauma victim? Who gives the orders? How much actual responsibility does the e m e r g e n c y m e d i c i n e resident have for trauma patient care? Is he ever in charge, and if so, how often ? Do the g r a d u a t i n g r e s i d e n t s feel comfortable takipg care of major trauma victims? Is an advanced trauma life support course provided? What is the relationship between the Department of Emergency Medicine Annals of Emergency Medicine

and the D e p a r t m e n t of Surgery? [Harmonious relations between these two d e p a r t m e n t s i m p r o v e p a t i e n t care and resident education.] Is this r e l a t i o n s h i p i m p r o v i n g or worsening? Do residents have to rotate to outside institutions to get particular necessary experiences, eg, trauma, not available at the h o m e institution? What do the residents think of this? If t h e y h a v e to go e l s e w h e r e for trauma, do they get adequate patient numbers, direct patient responsibilities, and teaching at these outside institutions ?

Procedures Who does procedures, eg, suturing, incision and drainage of abscesses, p l a c e m e n t of central lines, intubations, lumbar punctures, thoracotomies, etc? Does the emergency medicine resident get to do an adequate number and spectrum of procedures? Do the g r a d u a t i n g r e s i d e n t s feel comfortable doing all major emergency medicine procedures? Is a dog laboratory or human dissection laboratory used in procedure training?

Cardiopulmonary (Medical) Arrests [As with trauma victims, emergency physicians are expected to provide initial management of patients with cardiopulmonary arrests. To do so, w h i l e in residency t h e y m u s t be given the opportunity to assume increasingly greater levels of responsibility for these patients, ideally culminating in being totally in charge. In a medical arrest, if e m e r g e n c y medicine residents are always relegated to roles of responsibility secondary to those of physicians from other services, eg, internal medicine, cardiology, anesthesiology, they may not acquire the necessary skills.] Are there adequate numbers of patients with medical arrests? Is there a cardiac arrest or " c o d e " team in the hospital? If so, who is in charge of the team? Who is on the team? What is the role of the emergency medicine resident on the team or in a code? Does the resident have the opport u n i t y to be in charge of running codes, and if so, h o w often? 19:7 July 1990

Do the g r a d u a t i n g r e s i d e n t s feel comfortable taking care of cardiopulmonary arrest victims? Is an advanced cardiac life support course provided?

Supervision [While in residency, residents are supervised in various manners and degrees. Immediately on completion of residency, graduates usually will assume positions in an ED in which they are the only physician present at any one time. Therefore; the emergency medicine resident must acquire skills of independent judgment and medical practice. To do so in a manner that does not significantly and adversely affect patient care during the resident's training is an ongoing task. If the resident is continuously supervised by an attending physician "standing over his shoulder" at all times, it will be difficult for the resident to acquire the sldlls of independent judgment necessary for future clinical practice. Conversely, when at lower levels of skill, residents should not be placed in positions where, by being always unsupervised, they might cause significant harm to patients. Each program has addressed this issue in a variety of ways. Many programs have developed a system of gradually increasing levels of resident autonomy, commensurate with the gradually i n c r e a s i n g clinical skills of the resident.[ Who supervises the residents? What is the level of supervision? DO the residents think that this is too little, too much, or just the right amount of supervision? Have the residents experienced other levels of supervision, eg, at other institutions (allows basis for comparison)? Is a graduated level of responsibility, ie, with progressively less supervision, present? Is there any opportunity for a resident to practice medicine unsupervised at the bedside? Would the residents like to change the level of supervision? Are there any plans to change the level of supervision?

Research What research is being conducted in the Department of Emergency Medicine? Is there a research director and if so, 19:7 July 1990

what is his background and specific research training, eg, research fellowship? How involved are the faculty in research? Do certain faculty devote most or all of their time to research? How involved are the residents in research? Are residents required to perform a research project? How much time can a resident realistically spend on research? When? Where? Are funds available for resident research? What end-product, eg, published paper, conference presentation, results from departmental research? How m u c h publication is done by the faculty or residents? How supportive is the department toward resident research and publication? Does the program offer a research fellowship?

Prehospital Care (Emergency Medical Services) Is the program located at a base station (contains a radio station that supervises the prehospital care personnel, eg, paramedics)? How developed is the prehospital care system in the area? What do the residents think of their prehospital care educational experience? Does the program have an aeromedical, eg, helicopter, prehospital care service? If so, is resident participation in it mandatory? [Some residents may have either personal or family reasons to avoid flying.] How safe is it? Have there been any accidents or deaths associated with it? [Best asked sensitively - housestaff injury and even d e a t h have occurred in the past.[ Have any housestaff refused to fly in it and, if so, how have they been treated and what has been the outcome of that refusal?

Administrative Aspects [On completion of residency, emergency physicians are thrust into the "real" world, where knowledge of practical matters of clinical or academic practice is essential. Subjects include financial aspects of practice, r e i m b u r s e m e n t , practice management, contracts, types of employAnnals of Emergency Medicine

ment, medicolegal aspects, governmental interfacing, and quality assurance. In the past, residents have o f t e n acquired this knowledge by trial and error. To m i n i m i z e these mistakes and improve the success of emergency medicine specialists, residencies ideally should provide some education about these practical matters.] What type and amount of education is given in this area? Is it adequate?

Outside Conferences Do the residents usually attend local or national medical conferences? Are the residents given time off to attend these conferences? Are the residents provided any funding for attending? Are the residents rewarded for giving presentations at conferences?

Program Administrative Characteristics What is the program's administrative status: eg, division or department? [Emergency medicine residencies are frequently a d m i n i s t r a t i v e l y organized as a division contained within a department of internal medicine or surgery. As divisions, they may have limited autonomy in some important areas, eg, budgetary, that may have an impact on resident training or experience. Some educators feel that emergency medicine residencies ideally should exist within a separate department of emergency medicine to provide a level of academic autonomy and stability on par with other major clinical specialties. At p~esent, only a m i n o r i t y of all emergency medicine residencies are in autonom o u s d e p a r t m e n t s of e m e r g e n c y medicine.[ Are there any plans to change this status ? Are there any major political problems present, eg, severe interdepartmental rivalries, rancor, etc? If so, will they affect the program o1 resident training? [Severe interdepartmental rivalries have, in the past, perhaps contributed to the termination of some emergency medicine residencies.[ Are there any rumors of the impending demise of the program? -What is the level of support of the medical school, the university, the hospital, or the community for the program? Do you think that residency training 778/79


is sufficiently important to the division or department? To what extent is the program devoted to generation of income versus resident training? Are residents used exdessively as "ghost attendings" to see patients and generate income for the department? Is the department excessively entrepreneurial, ie, is it too much a business and too little a training program? [Best asked discreetly.]


ROTATIONS OUTSIDE THE ED Milieu What is the call schedule? How often are the intern and resident on call? Is there "short call" and "long call"? [Long call usually denotes taking admissions throughout an evening and overnight until 8:00 the next morning, while short call refers to taking admissions only until a designated time in the afternoon.] Is there a "night float" team? [A team that only admits patients in the evenings and nights.] What is the average n u m b e r of patients an intern admits each time on call? Approximately what time does the intern go home on the days when he is not admitting? How many of the patients are "service" patients and how m a n y are private patients? What percentage of the patients are emergency admissions? On the average, how m a n y patients is an intern responsible for on each of the services? Do the interns think this is an optimal number? Are there presently any limitations on the number of hours an intern or resident is allowed to work or are there expected to be limitations in place by t h e time the house officer starts the program? [Several bodies, both within organized medicine and legislative, are presently addressing issues of housestaff hours.] H o w m u c h " s c u t w o r k " does the house officer do? Are there blood-drawing and IV line personnel? How good are they? How frequently are they available? When are they unavailable? Who is expected to draw blood or start IV lines if these personnel do 80/779

not succeed? Is an adequate number of clerks and orderlies available? How good are they, ie, do they do their job appropriately? What is the typical number of members (medical students; interns, and residents] on each team? Do the supervising residents have responsibilities beyond the team's patients? How frequently are the supervising residents away from the team? Are the residents helpful and available to the interns? How much teaching do the residents provide the interns? Is it adequate? How "'good" are the residents? Are c h a r t r o u n d s or r a d i o g r a p h rounds done and are they valuable?

How available are they? How much teaching do they do? What are the strongest and weakest departments in the hospital? [Significant weaknesses in a major clinical d e p a r t m e n t m a y adversely affect the education and training of the emergency medicinb resident.]. Is formal training in selected tests and procedures (eg, electrocardiography, radiography, sonography) available?

Clinics Do the residents have clinic or outpatient responsibilities? If so, h o w much? Do the clinics have attending coverage? Are the residents provided appropriate teaching in the clinics?

Private Patients Do private physicians admit patients on their own? Who writes the orders on a private patient? Do the private physicians discuss their orders or patients' care with the resident? Do the interns or residents primarily perform "scut" or admitting histories and physicals for private physicians, with little or no educational value? H o w m u c h a u t o n o m y and responsibility do the interns and residents have for patient care? Do the residents think that this is the appropriate amount? Are orders carried out if they are written by someone other than the resident? Must the orders be countersigned by the resident first? [A countersignature guarantees that the resident will be aware of all his patients' care.]

Teaching Responsibility Are there medical students or physician assistants on each of the rotations? What is the extent of their responsibility? How good are they? When are they on call? How much instruction are the residents expected to give them?

Attending Physicians and Miscellaneous Who are the attendings and h o w good are they? What is their role and level of responsibility? How often are they on the ward? Annals of Emergency Medicine

FINANCIAL ASPECTS [As mentioned earlier, excessive attention to some noneducational aspects may be interpreted as undesirable by interviewers. Therefore some of t h e s e q u e s t i o n s m a y be o n l y briefly discussed and primarily with residents already in the program.] What is the pay (gross and net) for the interns and residents? What is the source of the funds, eg, private patient insurance reimbursement, local taxes, etc? Are there any changes expected in the amount or source of pay? H o w f r e q u e n t l y are the residents paid? What are the benefits? How much vacation? What types of medical, dental, disability and malpractice insurance, and maternity and retirement plans are offered? How much do they cost? How good are they? What do they cover, and what is the family or dependent coverage? When does the medical insurance plan first start, eg, does it start on the first day of internship or later? Are housestaff considered "'students" or "employees"? [This may affect the loan r e p a y m e n t s i t u a t i o n of residents.] What deferments are available for m e d i c a l school loans during residency? Do the housestaff have a formal organization, eg, a union? How effective is the organization? ]In certain regions, housestaff have formed a union to ensure that such 19:7 July 1990

issues as resident salary, w o r k i n g conditions, patient care, and due process are addressed in a more structured manner. In some cases these unions are e x t r e m e l y i m p o r t a n t to the residents.] MOONLIGHTING [Moonlighting is practicing medicine in the hours not "on duty" at a residency and is legally permissible in most states only after completion of an internship and receipt of a state m e d i c a l license. Because m e d i c a l school student indebtedness is rising steadily, r e s i d e n t s m a y find t h a t some amount of moonlighting is necessary to repay their loans. Residents w i t h familial financial obligations also may need to moonlight.] Is moonlighting formally permitted or prohibited by the program? Is it technically prohibited but informally allowed? At what stage of training can a resident first moonlight? W h a t m o o n l i g h t i n g p o s i t i o n s are a;cailable? How m u c h do the jobs pay? H o w m a n y shifts do the residents usually moonlight each month? LIVING CONDITIONS Where do most residents live? Is the program in an unsafe area? H a v e a n y of the h o u s e s t a f f b e e n physically assaulted inside or outside the hospital? Is resident housing provided, and is it adequate and safe? What are local a p a r t m e n t s like and w h a t is their typical rent? How m u c h do homes or condominiums cost? How m u c h commuting is necessary? What are the traffic, parking, weather, and shopping like? What are the outdoor recreational opportunities? W h a t c u l t u r a l o p p o r t u n i t i e s are available? What are the restaurants like? What do most of the residents do for fun?

MISCELLANEOUS Are uniforms, eg, scrubs, provided free? Are meals provided free by the hospital? How often? What is the quality of the food? Are any recreational facilities provided by the program? Are any spouses' groups, housestaff 19:7 July 1990

groups, etc, available?

SUPPORT SERVICES, S O C I O L O G I C A L ASPECTS [The following questions unfortunately may be interpreted negatively by interviewers and are listed primarily for enlightenment of the applicant rather than for actual use in an interview.] Does the program specifically address housestaff and spousal stress? If so, how, eg, workshops, support groups? Are counseling and psychiatric services available? Have there been any housestaff suicide attempts? Does the program address substance abuse, eg, by counseling, lectures, "diversion" programs? How have pregnant housestaff been treated by the program? Are they given appropriate medical/ scheduling consideration and maternity leave? Are housestaff actively discouraged from becoming pregnant? Are day-care services available? Are there any elements of sexism, racism, alcoholism, or other substance abuse within the program? CHARACTERISTICS AND ACTIVITIES AFTER COMPLETION OF TRAINING H o w w e l l do the graduates of t h e program do on the A B E M examination? H o w m a n y pass part 1? Part 2? Do the graduates have a n y particular difficulties w i t h the boards?

What do m o s t of the residents do when they complete training, eg, private practice, teaching, research fellowships? Where do they go? What types of positions do they secure, eg, partnership, h o u r l y employee, contract holder, subcontractor, m u l t i h o s p i t a l group, h e a l t h m a i n t e n a n c e organization, private hospital, university, etc? How easy was it for the housestaff to secure these positions? Did the program lend assistance to the residents seeking positions, and if so, to what extent? What is the relative number of positions available locally compared with the n u m b e r of p r o s p e c t i v e applicants? How satisfied are the housestaff with the positions they secured? Annals of Emergency Medicine

RESIDENT ASSESSMENT W h a t are s o m e of the residents' complaints? Does a n y o n e d i s l i k e t h e program? Could I speak to him? [Two ques-

tions that may be considered potent i a l l y i n f l a m m a t o r y b y an interviewer and thus should be used with caution.] W h a t are t h e s t r e n g t h s and w e a k nesses of the program? W h a t w o u l d you change a b o u t the internship or residency? W h a t do y o u t h i n k of the training you are getting? [The latter question

a very important, all-encompassing inquiry that should be asked.] H o w is the housestaff morale and esprit de corps? Are the interns and residents having a good time? Are t h e y glad t h e y c a m e here? Do t h e y consider the educational experience worthwhile? Are t h e y happy?

SUMMARY As the number of emergency medicine residencies increases, applicants to these programs are faced with the difficult task of selecting programs for their final match list. Resources to assist in this task have been limited: A personal interview is usually used by the applicant to assess a program. Optimal amounts and types of information may not be obtained by the applicant in this relatively new specialty. A list of suggested interview questions is provided to assist the applicant; this list can also be used by residency program directors and staff to give applicants necessary information. A critical evaluation of an emergency medicine residency is facilitated by judicious use of these questions. Future changes in the specialty and in residency training may necessitate periodic revision of this list. The author gratefully acknowledges the manuscript review by C Zeumer.

REFERENCES 1. American Medical Student Association: AMSA's Student Guide to the Appraisal and Selection of House Staff Training Programs, ed 3~

Reston, Virginia, AMSA, 1979. 2. Iserson KV: Getting Into a Residency: A Guide to Medical Students. Columbia, South Carolina, Camden House, 1986. 3. Raft MJ, Schwartz IS: An applicant's evalua~ tion of a medical house offieership. N Engl J Med 1974;291:601-605. 780/81

An applicant's evaluation of an emergency medicine internship and residency.

Applicants to emergency medicine residencies face an increasingly difficult task of evaluating a greater number of training programs. High-quality inf...
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