Medical Students, Advising, Match

Program Director Interview Series: David Snow, MD | Loyola Emergency Medicine Residency Program

Next up in our Program Director Interview Series is David Snow, MD, sharing details about the Loyola Emergency Medicine Residency Program. Dr. Snow tells us more about EM in the Windy City. 

What sets your program apart from others?

There’s probably quite a few things, from the first and most obvious part, it’s a new program. Being able to build something from the ground up with an experienced team that’s able to think about what’s worked and hasn’t worked in the past in regards to the overall educational mission with didactics, rotation schedule, services, all the way down to shift planning and operations. One of the incredible things about the last few months is being able to implement and strategize with people to make sure that what we are putting in place uses resources that Loyola has, in the best way, and uses them in a way that really optimizes the education for the residents. There are many things that we can delve into with that, but that’s one of the main things. It is a new program, but what’s in there is going to be so cutting edge in an educational vision way. It’s not novel in that sense or untested, it’s using things that we know are going to work. Also, it’s a new program within an extremely well established educational environment, with an amazing culture already in place under the guidance of our GME. Loyola has over 50 residencies and fellowships with about 800 trainees as it stands right now. The biggest question is why we didn’t have an EM program until now, but now we do. It’s a new program that is coming into an environment that is built around making sure the residents and trainees get what they need and programs hold up their end of the bargain.


Another unique aspect of our program is the specialty tracks that we offer. We wanted to make sure that we use the training and specialty experience of the faculty. Something I have noticed in my five years of being in residency leadership is that the sooner you get residents involved in certain things, the more likely it is to catch on. There was a time when I would wait ~12 for the interns to find their feet before they got involved and then those 12 months turned into more than a year, but by that time you lost an opportunity. These specialty tracks aren’t something that we are going to implement until after the first 6 months, but it’s going to be on the radar from minute one. Interns are busy and trying to figure out how to take care of patients, but the sooner you can start building on the potential possibilities that Emergency Medicine offers, the more likely they are to pick up on that. We have several faculty members with specialty experience from ultrasound, toxicology, education, simulation, global health, and EMS. It’s a host of things where they will get paired up with a mentor and we are building a curriculum around them to get what they need.

To speak on Loyola and what sets it apart, it is a Level 1 Trauma Center with one of the largest Burn ICUs in Illinois. It’s a quaternary care center which provides a unique set of patients that you wouldn’t get elsewhere including a large number of LVAD patients, hematologic and transplant patients mixed in with a makeup of patients that is needed for an EM training program.

What are the benefits of attending a 3 vs. 4 year EM residency program?

Knowing the background of the person answering this question is key. I remember being on the interview trail and surrounded by those with strong opinions on this subject, but not sure why they had them. I trained at a 4-year program and spent the last five years in leadership in a 3-year program so I can speak to this a bit more. My opinion is when people are trying to decide between a 3 and a 4-year program, I honestly don’t know if there is any true benefit of one vs the other. What it comes down to is the vision of the program, the residents that they are trying to graduate, and the educational and rotation model, and how this all fits with you and what you want. I chose a 4-year program, not because it was a 4-year program or not a 3-year program, but because I believed in the vision set out by the Program Director and the Chair, and it connected with me.

As we thought about whether a 3 or 4-year program would work at Loyola, one of the things that is most notable at a 4-year program is graduated responsibility. It was a model that I trained under and it worked very well for me and was one I honestly loved, but for other people, that model doesn’t work as well. At Loyola, being in the ED itself and knowing how learners learn and how this generation wants to learn, we didn’t think that a graduated model is one that works as much for our ED. With our model, we are able to get the education, experience, and exposure needed over the course of three years while also giving time for electives, ICU training and getting enough pediatric and EM exposure to where a fourth year is not needed.

What is something students may not know about your program?

I think one of the really great things about the department itself is just how involved the faculty are in education. If you read the bios of the faculty, you’ll start to think that they just hand out teaching awards to everyone that works there, but this really speaks to how heavily the faculty is involved in teaching not only the residents that rotate through the department, but also the medical students. The EM Clerkship has been a required rotation for about five years and we have about 16 students every month rotating through the department. There is a close relationship between the college of medicine and the department. Our Assistant Program Director, Dr. Amy Kule is responsible for Ultrasound teaching within the college of medicine and she runs scheduled workshops throughout the year for medical students. One of our core faculty, Dr. Trent Reed, who is the Assistant Dean and Director of Simulation Education, as well as the Vice Chair of the Department of Medical Education, also has a huge role within the college of medicine. During the required rotation, there are multiple workshops and teaching sessions and all of the faculty have a role to play in that. So one of the things I feel that students may not know about our program is just how involved and experienced the faculty is in teaching and how ready they are to pass that on to EM residents.

What range of USMLE/COMLEX Step 1 scores do you look for in an applicant for the program?

I’m not someone who believes in cutoffs. I have been asked if this is because we are a new program, to which I honestly answer ‘no’. I think the most important step for any Program Director is defining the type of residents that they want to have in their program. One of the first things that I tried to answer for myself and for the program was what are the core qualities that are going to fit best with the patient population, faculty group in the department, Loyola as an institution and Stritch College of Medicine. As we started to think through this, we noted some key characteristics that are important for this residency. When I know there isn’t a correlation between board scores and the ability to deliver patient care, it doesn’t seem fundamentally right for me to have cutoffs. I don’t think I will ever have cutoffs. Anyone that applies to the institution deserves a chance for that application to be reviewed to see if that applicant fits these core characteristics that are important to our program.

What kinds of opportunities for research exist? Do you look for residency candidates with research experience?

Research experience showcases many things; follow-through, the ability to lead a team, etc. However, there are many other ways to showcase those characteristics in your application. Someone with research experience shows certain characteristics that are enticing to a Program Director, but the lack of this in the file in no way means we will not consider your application – again, it comes down to the core characteristics mentioned before. As for opportunities that exist, it is a growing area within our department. We have many faculty members that are actively involved in research, both within EM and at the hospital and regional level. We have defined time within the residency to focus on scholarly work. There are absolutely opportunities for research within our program. There will be strong support from the faculty with the residents for research whether it is QI, direct patient care or education based. A lot of the specialty track directors will have a key role to play in this area.

Do you have opportunities to explore global health at your institution?

Absolutely. Dr. Theresa Nguyen is our Specialty Track Director for Global Health. She is also the Assistant Director for the Center for Community and Global Health within Stritch School of Medicine. She has worked in Ghana, Haiti, Vietnam, Peru, and the Dominican Republic. We have the people and infrastructure to tailor elective time to your specific interests within Global Health.

What are some qualities that your program looks for in applicants?

One is an eye towards teaching and education. Given our close ties to the medical school right now, there are going to be so many opportunities to be involved in that. That is a skill that we will help the trainee develop. Someone who is passionate about that will fit well with this residency. The second quality is someone that has an eye towards leadership. Leadership has many different definitions, but one that fits well is that drive to be the best that you can be, but also to help others be the best that they can be. Leadership is being on committees to improve the environment of those around you, being part of leadership of an organization, it’s an active role in research and seeing a project with a team through to completion.

The third thing that we are looking for is service. Loyola itself was founded in the principles of service. It’s about the patients and those around you. Service itself has many definitions, but to me and the team, it’s essential that your time with us is more than just about you. It’s about making those around you and the environment around you better than when you arrived. We want to train EM residents to lead the field of Emergency Medicine. That also has many definitions. It might be leading ACEP. It might be going to a small rural ED and you make it a better place for the patients, or help to train the staff. Leadership doesn’t have to be these big titles, it just goes back to what I spoke about before with what leadership means to us.

Every year these characteristics are going to be what we look for in an application. For our first PGY-1 class specifically, there are certain characteristics that will allow us to be successful. A pioneering spirit is one of the characteristics that my mind keeps coming back to. It’s that mindset that the residents will come in knowing they will be supported, knowing from an educational standpoint that what we have to offer is one of the most robust out there, and knowing that they are not test subjects for any of this. We, as an institution, will be watching them to ensure that they succeed in our training environment. Someone with a pioneering spirit is someone who wants to come in and showcase our department to rest of hospital. Someone who wants to leave in three years knowing that they were founding history of the program and had a truly influential role in its development. These are the unique characteristics that will help us flourish.

Can you describe any attributes and qualities that make applicants stand out?

I think one of the first things that I try to ascertain from an application is how much the applicant has delved outside of their own education in the last few years. This doesn’t mean that someone has to have done that, but I am always impressed by applicants who have been involved in committees, changing and improving things for medical school, or for regional and national organizations. Students that have spent a great deal of time volunteering and giving back to the community while also maintaining a strong academic portfolio. These applicants are always the ones that stand out the most to me. They show that it is more than just being about them and their education. By giving back to the community and improving things for those around them, there is real growth both personally and professionally. There’s something that sets them apart. It’s a level of understanding about themselves, what’s important to them, and where their career is going. They seem to have a lot more insight, which as Program Director, is something that is beneficial because then you are able to frame opportunities for them. During interviews, these applicants are able to ask questions that they need answered. That’s a huge part of the interview process that a lot of applicants will miss out on early in the interview season because they are nervous. Really asking those questions that at times might feel controversial is one of the most important part of the interview day. Whatever you can do to figure out where you want to be and what program is best for you, it’s the best time to do that. I feel that the applicants who have achieved those things throughout their prior training are better able to do that.

What are some of the benefits of being part of a new residency program?

The biggest one is helping establish a culture that will be present for as long as this program will be around. The faculty want this program to happen. They have pushed for this for almost 15 years. Like I’ve said, they are heavily involved in teaching, mentorship, and leadership. They want residents that care about Emergency Medicine that they can mentor, educate, and watch develop. These new residents are walking into what may be one of the most supportive and collegiate programs around. As I mentioned, the didactic and conference schedules are built around a methodology that is built utilizing the very best resources and educational models that are around right now. It will rely heavily on simulation, small group, and problem-based learning. This is not to say that we will move completely away from didactics, but as national conferences and Ted talks have shown us, shorter more focused presentations are the way didactics are moving. We are able to build that from the ground up. We are able to help faculty and residents build teaching models that are efficient and in tune with the educational vision of the program.

Education is one of the most important skills that I will help a resident hone. The ability to communicate is a key skill and imperative that we hone that skill throughout residency. From the first to third year, there is a curriculum that residents will be involved in. We will work closely with junior and senior residents to ensure they have what they need and review what they put together. Something that will be a big part of their training is how to teach and how they receive feedback.

What do you think will be some of your program’s biggest strengths during its first year and what challenges do you anticipate?

Strengths: The ED environment itself. We were able to sit with our Operations team and figure out from an Operations standpoint what would be a model that is the most beneficial for the residents from an educational standpoint. We will be moving to a pod based system which allows 1-1 resident and attending staffing. Having this model allows attendings to know what the resident is doing, not from a controlling standpoint, but from a shift standpoint. You know what they are able to handle on top of their current tasks and workload. If multiple new patients arrive, knowing the residents and knowing if they are busy with consults or procedures, this 1-1 model really works for them and the attendings. You are a team when you are on shift. You know who to go to with questions. You help each other get out on time. This allows for teaching and mentorship to happen in the moment.

One of the other strengths is the supportive nature of hospital and the GME department. When it came time to get approval to even move forward to the ACGME level to build a program, every Program Director and Fellowship Director had to agree that an EM program was good for our institution and current residents and fellows. That means that even if one individual did not feel that was the case, then we could not have progressed with building a program. The downstream effect of this is that every Program Director, Resident, and Fellow knows that this EM residency is coming. They all had their input to ensure we were fitting something within their educational model. Everyone wants this to succeed. We want our new residents to showcase our strengths as they begin interacting with these colleagues of ours. It is a really exciting time for this institution.

Challenges: There are some inherent challenges that people will think of when thinking of a new program. Despite the concern, we can already circumnavigate some of these. The ones that we can already nullify are that it’s a new program thus the educational environment and training curriculum is new and thus completely untested. There are some new rotations we have built specifically to get more exposure in things that we feel are needed in residency. Pediatric sedation is one of those rotations where we know it’s a procedure that is hard to come by no matter where you train. Pediatric ICU attendings are doing this on a routine basis in our hospital, so that is a unique learning opportunity and something that is a required skill of an EM resident. Other than these unique and new rotations, all the other rotations are ones that have been experienced by trainees at Loyola for many years. The GME department and Program Directors know that these rotations work, know that the EM residents are not removing educational opportunities from current residents, but that they are part of the team. That concern of being new and experimental essentially goes away.

Another challenge is something that maybe isn’t as explicit, but yes our Faculty are very well versed in teaching and mentoring, but for many of them, they have not been around EM residents in a few years. The leadership team knows this and are aware of it. We have many scheduled teaching sessions and workshops with faculty to discuss specifically how to mentor and educate different levels of EM learners and to strategize on the mentorship aspect and EM-specific learning. I have no doubt that given the experience and current educational experience of the faculty, this will be something that is easily navigated by them, but as a Program Director, I have to be aware that this is still something that requires attention in the coming months.

The other challenge is that there are no other EM residents around. That is going to be a challenge for the new class. What’s important is to make sure the faculty themselves are available and collegial so they can fill some of that void of not having senior residents to lean on for support. On top of that, we felt it was important to have a dedicated orientation rotation. I didn’t want to just have a few days with them and with each other. We felt it was important to have an entire 4-week rotation at the beginning of the PGY1 year for the residents to get to know each other and get to know us as both faculty and leadership. They will be able to get to know the ED and the staff within the department, with the goal being that at the end of the rotation, they will have a supportive network with us and within their own class. On top of this, while on their off-service rotations, our residents will come back for our weekly conferences every week, almost 100% of the time. This is a huge plus for both education and solidarity within the group. I certainly cannot produce senior residents for the new class, but my hope is with these other things put in place and that we have available to them, that becomes something that is not as much of a disadvantage. Going back to that Pioneering aspect, there is a certain trait present within those individuals that they will be okay with not having those residents around and they will thrive in that environment. Looking down the road, knowing how close we will be with these residents in three years as peers and mentors, that’s an amazing thing.

How will feedback be provided to residents and how often will they be evaluated?

Resident evaluations will come from multiple people, in a variety of different settings. Evaluations will come from the faculty working on the shift with you. We are building our shift model to be a team-based model. You will work one on one with your attending and will have similar start and end times for the shift. That allows the faculty member to evaluate your performance and give feedback at the end of shift. There will also be evaluations at the department level with monthly meetings where we discuss the class as a whole and think about where they are collectively. There will be regular meetings with the program director to both think about trajectory for what the resident wants to do and look for areas for improvement that we can tease out. Evaluations will also come from the educational curriculum, nurses, and their peers. There will also be pieces built in for feedback from patients. I’ll balance the need for feedback with how much is too much, with knowing they are in residency to be the best physician that they can be. The key is knowing where areas for improvement exist, as they do exist for every resident.

 

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