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Emergency Medicine Interview


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I'm a recent graduate and I have an interview coming up very soon for an emergency medicine position.  I wanted to hear from some people who have been through EM interviews so I can get an idea of what to expect, especially as a new grad.  I have been on interviews for other specialties in the past and I have been pop quized with clinical scenarios and "how would you work up this patient" type questions.  They were totally unexpected at the time and completely threw me off.  Has anyone had a similar experience in EM?  What type of questions were you asked?  Thanks, your help is much appreciated.

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Yes, I was "pop quizzed" when interviewing for EM jobs, at every single one of them.

 

It makes sense because if you don't know how to work up a chest pain or the differential diagnosis for shortness of breath, or even abdominal pain, then you're not ready to work in EM.

 

Now, I don't mean you have to know and do everything perfectly, but you presumably did an EM rotation, so be prepared to at least have some thoughts on DDx and testing/treatment of the most common complaints in EM.

 

They might catch you off guard, but EM is all about catching clinicians off guard! You have to know how to think on your feet, don't freeze, work as a team, and don't get tunnel vision.

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I have regularity interviewed applicants over the years.

 

While I have almost never hired a new grad ( exactly two in maybe 30+ years as a hire fire guy), I always slip a couple standard scenarios into the process.

The reasons are simple: regardless of your credentials, I want to know how you think.

I really do not care how passionate you are or how you feel about issues, I want to know if you can take a set of facts history and labs), and generate a differential diagnosis, and whittle that list down into probabilities versus possibilities.

 

We may even differ on interpreting the same set of facts, but your logic on how you arrived at a conclusion as to what the facts represent makes for me the difference as to whether or not I consider you a serious candidate.

 

There us really only so much small talk that the interview can generate...

 

The primary purpose is twofold:,to guesstimate how you will fit into the group, and whether or not you can think like an ER doc.

 

Talking your way through scenarios is for me the best indicator if the second.

 

My advise is, be yourself, don't try to blow smoke.. Don't say you can do procedures that you cannot, not read EKGs if you cannot,.

 

Though you will be nervous, try and remember that there is SOMETHING about you they liked which caused them to invite you in fir an interview. Trust your training, and understand that though you will not likely do as well as a seasoned EM guy, doing EM requires an ability to multitask and handle several different sets of facts concurrently. If you can do THAT in a cogent coherent and logical manner, then you can be taught EM.

 

Good luck

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55 y/o hypertensive diabetic black male rolled over in bed at 0309 and became acutely and violently vertiginous and nauseated. Went back to sleep. Still symptomatic at 0700, called EMS and came to Ed.

 

What additional hex and physical exam findings are you looking for? What studies would you like? What is/are your initial differential diagnoses... What worries you the most?

 

( have all lab results , EKG, ct, MRI, echo results for candidate to get if they ask).

 

I would like to hear that positional vertigo, tho on the list, is NOT a primary concern. And would like the candidate to entertain basilar artery insufficiency, cvs, arrhythmia, cardiac ( particularly occult PFO),, metabolic, CAS, etc.

 

#2, ( a case I presented here 6-7 years ago). 14 day neonate presents at 0800 with " not acting right", somnolent and decreased responsiveness. Again, what or, hex, studies, labs, procedures would you do?

 

What would you want to do immediately?

 

Normal vitals. All labs nl except severe metabolic acidosis, and mild hyponatremia, hypochloremia.

 

( essentially I want old school approach to neonatal sepsis, and candidate to figure out why acidotic with normal lp would want a pretty thorough ddx, working his/her way to acute alcohol intoxication ( mom was mixing formula with moonshine)

 

#3. 23 y/o with pruritis and hives.

 

What history is needed? Any labs/ studies?

 

Looking for common sense approach to the sx, with final diagnosis being non icteric hyperbilirubinemia due to severe hepatitis B and a severe uti.

 

4. 8 year old wm with peri umbilical cramps pain and nausea with vomiting.

 

Looking for decision algorhythms as to whether or not ct is indicated versus u/s, versus MRI ... Versus simply calling surgeon when exam shows mcburney point tenderness, leukocyte sis and normal urine.

 

That sort of thing.

 

I always pick a case the we have had in the ED and wrestled with the issues ourselves.

 

For fillers, I would ask whether or not cultures are warranted in sore throats, to explain the basis of rHoGam, or to describe work up of dyspnea in a pregnant lady.. Extrem u/s, ct angio versus v/a scan and why?

 

Again, is done in an encouraging method, allowing the candidate to get as far as he can, then asking him to consider whether or not another diagnosis is worth looking at.

 

If I have a true hot shot genius, I will ask him the derivation of the Aa gradient formula, and how to compensate the gradient for change of geography Denver versus sandiego.

 

If he can do that, I will teach him how to do it in his head.

 

And then go to lunch.

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I'll admit that acute alcohol intoxication in a neonate might have taken me a loooooong time to figure out.

 

And holy crap, was that a real case? Mom mixing formula with moonshine? When's the Parent of the Year Award ceremony?

 

Sorry for the hijack, please continue.

 

For the record, for a new grad, I don't know if the cases would be quite that esoteric. RC, do you really pose these cases to someone looking for their first job?

 

I got mostly the typical PANCE scenario of 68 y o hypertensive male with no h/o kidney stones presents with flank pain. Of course it's always the aorta in these hypotheticals! At least keep it at the too of the DDx until proven otherwise.

 

Another fave of interviewers are abdominal pain. Review some cases and DDx, labs, etc.

 

Of note, we just had a student the other day on her fourth medicine rotation who presented an abdominal pain but never thought to ask WHERE on the abdomen the pain is, and didn't examine the abdomen either! WTH?

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No, these cases are tough. I do not expect an automatic "got it"... What I am looking for is the thought PROCESS.. What are you thinking.. What would you do with information given?

Yes the 14 day old was a real patient, blood alcohol 240 -ish mg%.

I did/do not know if a 14 day old had lactic dehydrogenase enough to start detoxifying the ethanol. I was at johnson memorial in Smithfield county, nc.. And transferred kid to wake Forest medical center.

 

What I would expect is that the candidate would not send the kid home... Would have started gent/amp IV pending lp results, gotten a cat scan, cxr, sepsis w/u, and then ( if stumped) consult, or go through listing of anion gap acidosis to arrive at why the kid had one.. ( which is how I made the dx). The answer was in the labs, the question I would have is whether or not the candidate would reconize that fact, and whether or not his " sick/not sick" sense was tweaked.

 

The cases are hard on purpose.. These are real patients... The 14 days old came into fast track... And I want to know how you think.

Again, we rarely if ever interview newbies... I do not think newbies should be in the ED unless they are gonna get at least a year mentor ship and close hand holding.

 

Unpopular opinion , that, especially here on the forum. But it is what it is.

 

My feeling is that patients wil be patients, and present with the whole gammit of diagnoses from common to esoteric, and I expect that you as a provider, should be up to the task of at least considering the esoteric before discharging the patient.

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I absolutely agree that you can't expect only the non-esoteric to come through the door. And yes, the process has to be there, the sick-not sick acumen is key.

 

Getmeoutta, me (for admitting I might not have though of etoh in the newborn) or the PA student? ;) No drunk babies at the Hawaiian clinic!

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our E.D. is divided into fast track, peds, intermediate, psych, and main. we also have some inpt and obs responsibilities depending on shift.

when we interview folks we want to make sure they are comfortable dealing with folks in all these situations so typically we ask some "really sick kid" questions, some psych questions, some adult nightmare questions, etc.

one of my chiefs always likes asking a question about a cancer pt with neutropenic fever...of course the way he presents it, the pt doesn't really know they have cancer because they aren't totally with it and they just keep talking about "bad bones" and shots(...chemo...) every month....which leads many folks down the RA pathway instead of the CA pathway.....he just wants to see the reasoning: do they get an old chart, do they check appropriate labs, do they do the appropriate septic workup and ADMIT, etc.

we had a guy a while ago who thought it was a viral syndrome, checked no labs, and reviewed no charts. he didn't get the job...same guy also missed a no brainer child abuse question about a spiral femur fx with a wonky story from a babysitter....

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