EMRA Fellowship Guide, 3rd Edition

Observation Medicine

Authors

Nathan Roberts, MD, PhD
Chair, EMRA Research Committee
University of Michigan

Anna Heffron, MD, PhD
Vice Chair, EMRA Research Committee
Icahn School of Medicine at Mount Sinai

Faculty Reviewer

Christopher Caspers, MD, MBA, FACEP
Professor and Chair
Department of Emergency Medicine
NYU Langone Hospital - Long Island
NYU Long Island School of Medicine

Special thanks to our 2^nd edition writing team

Joe Khoury, OMSIII
Michael Oluwole, MSIII
Manpreet Singh, MD

INTRODUCTION

Description of the specialty
Observation medicine trains emergency physicians to be leaders in education, research, administration, and clinical care in the context of acute care beyond the ED setting. Physicians trained in this specialty have a broad knowledge base regarding clinical operations, quality improvement, patient safety, observation patient selection, and patient flow, such that they are capable of developing and running an observation unit. As such, physicians in this specialty often engage in quality improvement and/or research projects.

History of the specialty/fellowship pathway
With the rapidly aging population, increased emergency department and hospital crowding, and increased ED boarding, the focus on patient flow has intensified. One of the solutions to both hospital and ED overcrowding has been the development of short stay/observation units. These units offer an alternative to inpatient admission by providing efficient and effective time-limited health care. Patients who are treated in these units are those whose expected care will be completed within 24 hours and who have limited severity of illness or intensity of service needs.

These units started with protocols for cardiovascular emergency patients, but now serve a variety of patients with medical and trauma-related emergencies. While in some hospital systems the care of these patients falls to the internal medicine service, in many others care remains the responsibility of the emergency physician. As a result, fellowships have arisen to help train and prepare emergency physicians both clinically and administratively to lead an observation unit.

Why residents choose to follow this career path
This is a growing specialty designed for physicians who aspire to be leaders in developing, managing, and working clinically in observation units. As a training environment, the observation unit is excellent entry-level training for ED administration, and many former observation unit directors have gone on to become ED medical directors.

How do I know if this path is right for me?
Are you interested in addressing patient flow? Are you interested in developing protocols to help observation units run more efficiently? Would you like to develop an observation unit at your institution? If the answer to any of these questions is yes, this may be the fellowship for you.

Career options after fellowship
Completing this fellowship provides you with the skills to be a leader in observation medicine. Not only will you specialize in the care of these patients, but you will also have the administrative skills to develop and run an observation unit. Many graduates move into careers in ED operations and administration. Some also become involved in resident or advanced practitioner education and expanding their acute care knowledge base. Others find their niche in research and/or quality improvement projects.

Splitting time between departments
Those who complete fellowships do not typically split time between departments because affiliated observation units are often staffed and managed by emergency physicians. However, most observation medicine specialists will work more shifts in the observation unit than their colleagues. Also, you will likely need to factor in time for research and/or administrative work in addition to your clinical shifts. Finally, some hospitals have two observation units: one within the ED and one staffed by hospitalists. A strong ED observation unit director would be well-trained to oversee both, which would involve interface with the Department of Medicine hospitalists.

Academic vs. community positions
Deciding between an academic or community practice environment is a very personal choice. Both academic and community programs across the country have developed observation units and offer administrative/leadership positions. Those with strong interest in research tend to gravitate toward careers in academia. Those with education interests also gravitate toward academia or community-academics. There are health systems that employ observation medicine directors to oversee all observation services within multiple hospitals.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs

Emory University School of Medicine

Good Samaritan Hospital Medical Center-Progressive Emergency Physicians

Spectrum Health-Emergency Care Specialists

Differences between programs
All 3 available fellowship programs have similarities:

Length of time required to complete fellowship
This is a 1-year fellowship, unless you earn an advanced degree (such as an MBA, MPH, or MHA) during fellowship, which would take 2 years.

Skills acquired during fellowship
You will acquire administrative, leadership, and research skills and continue to expand your knowledge base and clinical skills within observation medicine.

Typical rotations/curriculum
Emory: The fellow typically spends 64 clinical hours per month as an emergency medicine attending physician, with clinical coverage of the observation unit as a part of clinical shifts. Much of this time will be spent in an observation unit, but there will be time within the regular emergency department as well. The fellow will also serve as an assistantunit director, attend monthly didactic sessions, and carry out a research project related to observation medicine.

Good Samaritan Hospital Medical Center/Progressive Emergency Physicians: The fellow will spend 22 clinical hours per week with a minimum of two shifts per week in observation units. The fellow will attend operations, utilization management, patient throughput, and system observation meetings as part of the curriculum.

Spectrum Health/Emergency Care Specialists: The fellow will spend on average 16 hours per month as an emergency medicine attending working clinical shifts and 24 hours per month as an observation medicine fellow with attending oversight. Sixteen hours per week will be spent working clinically, and eight hours per week are dedicated to administrative work and didactics. The observation clinical shifts will be spent covering a 25-bed observation unit of Spectrum Health Butterworth Hospital, which sees an average census of 500 visits per month and includes a 4-bed EmPATH (Emergency Psychiatric Assessment, Treatment and Healing) unit. The fellow will attend various lectures, journal clubs, department meetings, and operation meetings and will participate in research throughout the academic year.

Board certification afterward?
There is no board certification in this field. However, Emory offers the opportunity for advanced coursework/certificate/degree work.

Average salary during fellowship
Because this is not an ACGME-accredited fellowship, you will likely be offered a competitive salary.

PREPARING TO APPLY

How competitive is the fellowship application process?
There are a small number of applicants per year. However, this is a small field with limited fellowship opportunities.

Requirements to apply
You must be graduating from an emergency medicine residency or be an EM graduate who is board-eligible or board-certified.

Research requirements
Completing research prior to fellowship — specifically research that pertains to observational medicine — is strongly encouraged.

Suggested elective rotations to take during residency
It would be wise to spend a dedicated rotation to work in your department’s observational unit. Other elective rotations to consider include research, cardiology/stress testing, neurology, neuroradiology, and ED administrative months.

Suggestions on how to excel during these elective rotations
Be enthusiastic, engaging, and easygoing. Arrive early and stay late. Read every day and continue to expand your knowledge base. Treat every day as an interview day, and be courteous to all. Aggressively seek out mentors and future letter-writers.

Should I complete an away rotation?
If your home institution does not have a separate observation unit within your department, then it would be worth considering an away rotation.

What can I do to stand out from the crowd?
The best way to stand out from the crowd is to demonstrate a strong interest in observational medicine with your CV, personal statement, and interview. Have a clear vision for your career after fellowship. Be clear, concise, and friendly during your interview. Have ideas to share with your interviewer about how the fellowship training might be used in your future career aspirations. It would be ideal to have a research project near completion by the time of your interview. Being chief resident will help your application but is not required. Assume meaningful leadership roles. Finally, ensure that you meet all deadlines, have strong letters of recommendations, and practice your interview skills, ideally with faculty familiar with observation medicine.

Should I join a hospital committee?
If your hospital has a committee that interests you and on which you can have meaningful contribution, then this experience may strengthen your application. Anything that shows a resident’s ability to engage and play a leadership role, even on small committees or projects, would be helpful. The ability to build relationships with others, and other departments, is important.

Publications other than research
Publications other than research — such as blog posts, newsletter articles, clinical case publications, etc. — are encouraged, especially in observation sections at national levels (i.e., ACEP).

How many recommendations should I get? Who should write these recommendations?
Try to get three letters of recommendation (minimum of two), one of which should be from your program director and/or department chair. If possible, a strong letter from a physician who is known within the observation medicine community or spends time working within an observation unit would be useful as well.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, you can still be competitive. The key is to continue to be involved in leadership and/or research opportunities and to continue to gear your resume toward observational medicine. If you can, seek out shifts in observation units. Attend conferences about observational medicine, and consider publishing educational articles. Consider joining a relevant hospital committee.

What if I am a DO applicant?
There are no barriers for DO applicants.

What if I am an international applicant?
International applicants are encouraged to contact the programs early to see if their visas are accepted. English competency is required.

APPLICATION PROCESS

How many applications should I submit?
Apply only to the programs you would consider attending.

How do I pick the right program for me?
Look for the one that best aligns with your future career interests. You should be excited about the program. You should feel like you enjoy the staff and clinical environment and would be happy there for the duration of your fellowship. Do not ignore your inner voice if it is telling you a particular program is not the right fit. The program should also be in a location where you can see yourself happily living for one to two years.

Common mistakes during the application process

• Grammatical errors in your personal statement
• Missing application submission deadlines
• Submitting an incomplete application
• Having a CV that does not display an interest in observation medicine
• Choosing letter writers who are not strongly supportive of you
• Being rude to ancillary staff/program coordinators
• Asking questions about the program during an interview that could easily be found on the program’s website
• Not knowing your CV well and thus being unable to answer questions about it during your interview
• Falsifying parts of your CV

Application deadlines and Start Dates
Fellows typically start their program on July 1; please see individual programs for application deadlines and specifics.

Tips for writing your personal statement
Try to use your personal statement to show your personality and character traits that suit you well for a career in observation medicine. Avoid repeating your CV in your personal statement. This is your time to show your personality and share your passion for the field. Readers are interested in understanding why you want to pursue observation medicine and how it fits in your future career goals. The best personal statement reads as a story and captures the reader’s attention. Is there a particular patient, mentor, or clinical scenario that led to your interest in observation medicine? If so, let this story be the focus of your statement, and end the statement with your career goals and aspirations after completing a fellowship.

Is this a match process?
No.

What happens if I do not obtain a fellowship position?
If you are not selected for a fellowship position, discussing your application with the fellowship program director can provide insight into how you can strengthen your application for the future. Asking a trusted mentor to critically review your application (preferably a physician in a leadership role) can also identify areas of weakness. Practice your interview skills, and apply again for fellowship. Consider also applying to related fellowships (such as an administration fellowship). Attend national conferences, and continue to seek opportunities to show your interest and become involved in the field. Another option is to work with your employer to develop your niche within observation medicine within your institution.

INTERVIEW PROCESS

How do I stand out from the crowd?
Practice your interview skills prior to your actual interview to place your best foot forward. You want to come off as confident, engaging, and interested in their program. You want to show them you would be a great fit. Don't be the applicant who talks too much, and don't be the one who doesn't talk at all. Do not be vague or uncertain about your decision to pursue this fellowship opportunity. You also don't want to come off as arrogant or shy. Search the program's website and make sure the questions you ask during your interview are not easily answered on their website. Know your application well, and be prepared to answer any questions about it (such as about your personal statement, activities on your CV, etc.)

What types of questions are typically asked?
Why are you interested in completing an observational medicine fellowship?

Why are you interested in completing this fellowship at our institution in particular?

What are your 5- and 10-year career goals?

Tell me more about your research interests.

What has been your clinical experience working in observation units? How much exposure have you had?

Tell me more about your CV.

What are your strengths and weaknesses? 

How many interviews should I go on?
Because there are limited fellowship positions, it is recommended that you attend all offered interviews.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

• Graff LG. Observation units: Implementation & Management Strategies. Dallas, TX: American College of Emergency Physicians; 1998.
• Ross M, Graff L, Bohan S. Operations: Flow - The Role of Observation Units, RTUs, in the Emergency Department. In Strauss R, Mayer T, Salluzzo R, Kaplan J, Weintraub B. Emergency Department Leadership: Principles and Applications. New York, NY: McGraw-Hill; 2013.
• Ross MA, Graff LG. Principles of Observation Medicine. Emerg Med Clin North Am. 2001;19(1):1-17.
• Ross MA, Wheatley M, Leach G, O’Malley R, Osborne A. Clinical Decision Unit Manual. Electronic media, Macintosh i-Book. 2012.

Important skills to practice while in residency to prepare for fellowship
Work on your clinical skills and knowledge base, especially as they relate to observation medicine, research skills, andadministrative and leadership skills.

Tips on how to succeed as a fellow
Fellows who are most successful are those who are passionate about their fellowship and develop their niche within it. Show up early and stay late for your shifts. Read every day to expand your knowledge base. Find a project that interests you and do it well. Become involved on hospital committees and in research projects. Stay balanced to protect yourself from burnout. Take every opportunity your training program offers, and make the most of your time as a fellow.

CONCLUSION

Additional Resources

Journal articles

• Mace S, Shah J. Observation Medicine in Emergency Medicine Residency Programs. Acad Emerg Med. 2002;9(2):169-171.
• Wheatley M, Baugh C, Osborne A, Clark C, Shayne P, Ross M. A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency. Acad Emerg Med. 2016;23(4):482-492.
• Huffman A. Use of Observation Units Growing. Ann Emerg Med. 2013;61(2):A21-A23. 
• Pena M, Wheatley M, Suri P, Mace S, Kwan E, Baugh C. The Case for Observation Medicine Education and Training in Emergency Medicine. AEM Educ Train. 2019;4(Suppl 1):S47-S56.

National organizations

ACEP Observation Medicine Section

SAEM Observation Medicine Group

Online Resources

ACEP Observation Services Toolkit

Conferences

Observation Care – Held annually

Michigan College of Emergency Physicians, Observation Medicine – Science and Solutions in September

The World Congress’s annual Observation Management Summit

Observation Patient Management Congress by Global Media Dynamics

How to find a mentor
There is no current centralized service that pairs interested physicians with mentors in the field. We recommend finding physicians currently holding leadership roles in observation units to help introduce you to this field. Certain medical societies, such as ACEP, have observation sections you can join and get more information. Your program director is another good source of mentorship. Finally, you can consider emailing the observation medicine fellowship programs and asking their leaders for advice/mentorship.