3 year vs. 4 year EM programs

[donkeykong1]

My school has about 20 EM spots altogether under their GME, all being AOA accredited 4 year programs. All the 3 year programs are on the ACGME side. Unlike other specialties, EM seems like the only one to have programs differing in length. Those being 3 years vs. 4 years.

What accounts for this?

Would the training be the same in both both programs?

Would a resident coming out of a 4 year program be more attractive to recruiters, since they have an extra year of training/research?

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[pinipig523]

When I applied for jobs, they were very receptive to the 4 year program.

 

[DeadCactus]

Most people feel there is no difference between the two in terms of ability or employment. The four year programs tend to be places that can get away with a four year curriculum because their name is enough to still attract applicants...

 

[gro2001]

At least some academic programs tend to be hesitant hiring fresh graduates of 3 year programs. Apparently this is due to the fact that otherwise you could have the awkward situation of having a 4th year resident presenting to someone who is essentially at the same level of training. Not to say that a 3 year program bars the way to an academic career. It just may require either a fellowship or working at a different institution for a bit.

 

[Arcan57]

Do a search, this has been hashed out repeatedly.

 

[WilcoWorld]

Arcan's right, but I'll summarize.

Can doing 4 years instead of 3 you get a job?
-Maybe, in a few specific instances, it will make the difference.

Is it necessary if you want to go into academics?
-Absolutely not. A fellowship will give you at least as much, if not more of a leg-up. And neither fellowship nor 4 years are as important as being in the right place at the right time.

Should it be the deciding factor in your rank list?
-Only if all else is equal. Things like familial proximity, personal fit, and where you want to end up practicing should bear much more heavily on your decision.

 

[DeadCactus]

and where you want to end up practicing should bear much more heavily on your decision.

Kind of tangential but, to avoid making a new thread, how important is where you want to end up practicing? I hear it mentioned a lot. I see the logic behind it but is it so bad to train somewhere else just because you want to see somewhere new?

 

[EM_Rebuilder]

THis has been covered numerous times and everyone on here and nationally from a four year program will have a different opinon than those from a three year program. I always feel compelled to answer since I am a product of a four year program...

Academics: It was already well said above. 3+fellowship in some ways is probably better than a 4 year program.. 4 year+fellowship is even better, but thats now 5 years of PGY training. Most of getting a job at a desired education center is knowing the right person or being at the right place at the right time....

Private World: Some people say otherwise, but I have talked to enough people that do actual hirings, and they have all told me if given the choice between two applicants, the 4 year graduate with moonlighting experience is typically the most desirable person. IN reality, all of us can find some sort of job somewhere simply by being BE/BC. There will be very few isolated occasions when this truly will make you stand out.

Competency: Three years make you a competent EM physician as does four years. There was a study to see if four year grads had a high pass rate on the Qual exam... they were equal to the three year grads... In reality, I always said if you told the EM Intern that if they pass the Qual Exam first year, they will be BC... I think their pass rate would be just as good and probably better. That test is difficult, but its still something that anyone thats been to medical school and knows how to study can dedicate themselves to review books and do well...

Showmanship: I think being in a four year program tends to 'round you out' a bit better when it comes to truly running a busy department. This is what I think is hard to put a value on and hard to measure. There will always be three year grads that are simply awesome and do a better job at 'running the department', and there will always be four year grads that are lazy and 'just get by'. I think the four year program simply has a great chance of making you a very well rounded doc...

Knowledge Pile: I look at EM as a specilaty and in my mind there is a 'pile' of stuff sitting at the start of residency that you must minimally digest... is that easier to do in three years or four years?

Why I chose a four year: I went to probably one of the least known/name recognition programs that is still a four year program. I interviewed at 12 or so places and rotated at my program as a student.. I ha dother options. I've always considered myself a bit behind the eight ball than my peers.. I tend to be a below average type person when it came to medical school. I wanted to be the best EM physician I could possibly be. To me, it made sense that I would be 'that much better' by being at a four year program... the pace was a bit slower, a little more time to digest information, etc etc. For me, it worked well. I consider myself everybit of an average EM physcian and like to think I am above average.

 

[pinipig523]

I just finished my last shift at a very well known 4 year program. I would do it again in a heartbeat. 4 years would be my choice. No regrets.

 

[edgesofsanity]

Kind of tangential but, to avoid making a new thread, how important is where you want to end up practicing? I hear it mentioned a lot. I see the logic behind it but is it so bad to train somewhere else just because you want to see somewhere new?

The best way to answer that question is to ask on the interview trail where their graduates' post-residency job locations have been for the last 2-3 years. Going somewhere new is great for training; just recognize a lot of factors may end up anchoring you there. Seeing the dispersal rate of graduates may help you see the program's ability to help you locate a job where you want.

Notably, a lot of getting a good job without a recruiter or large national organization is networking - I know that I would recommend to my boss trainees from my program (after a quick staff-to-staff background check if I don't know the resident personally of course); and I imagine most attendings out there probably do the same.

 

[SoCuteMD]

.

 

[KarlPilkington]

I think the days of doing a 3 year and going straight into academics are pretty much over.

You can still do a 4 year and go straight into academics but its getting tougher.

Moonlighting as a resident and having a 4th year to "run the department" are both helpful, but its not the same as getting out and working as an attending. No matter how long your residency is, that first year out as an attending has an amazing learning curve.

I did a 3 year residency, then worked in the community for a year, got a good amount of "academic" stuff done in terms of publications/lectures/presentations, and am now going back into academics. I found a lot of academic shops were very interested in folks who had spent some time in the community.
If I could do it over again, I wouldn't change a thing. I would have been a really crappy attending without some time on my own to figure out the basic nuts and bolts of being a real doc. I still have miles to go, but I feel 100x more confident now then I did a year ago.

There are some great 4 year programs out there, but I'm not sure having more electives or time as a supervising resident would have taught me nearly as much as I've learned out on my own.

 

[jbar]

As a resident in a 4 year program, I object to your choice of words here. The places that have 4 year programs are the places with an interest in providing something more than just emergency medicine training. While I'm sure that 3 year programs produce perfectly adequate emergency medicine physicians, there's not a lot of time in a 3 year residency to develop a niche within emergency medicine. And while yes, everyone likes to say that 3 years + fellowship is more valued than 4 years of EM residency, the truth is that residents from 4 year programs go on to fellowship at much high rates.

I think you have to ask what a specific four year place gives you. Some places you are still spending 6 months doing non ICU floor months, so you can ask how much that gives you. As to the fellowship thing, if you are going to be doing a fellowship anyway why do 4 years of residency and then a fellowship, especially if you are thinking about doing something that has a 2 year residency like tox. If you are looking at 6 years of training, shaving a year might sound pretty good.


The truth is that I was pretty sure I was going to go to a 4 year place, and I ended up falling in love with a 3 year program. I feel that I have the time here to develop a niche (I'm on the Sim Wars team, I am involved in ultrasound etc). So go where you fit the best. But keep an open mind. I found on the interview trail all the 3 year places were trying to convince me that a 4 year place was a waste of a year, and the 4 year residencies were telling me that 3 year programs don't prepare you well enough. I think neither of those statements is really true.

 

[AmoryBlaine]

Even though this has been discussed I'm going to bite as a recent 4 year grad.

Emergency med is a 3.5 year residency. People say this as a joke or sort of tongue in cheek but it is true. I think if you do a solid 3 year program you are going to have a few more "oh ****" moments as a junior attendings and if you do a 4 you are going to be a little annoyed towards the end of your 4th year that you are still presenting to an attending.

It is crazy to say that the training is equivalent, it clearly is not, 4 year grads see more. That said 97% of the physician you will be is up to you. The best 3 year grad can hang with any 4 year grad and the worst 4 year grad suck as much as you'd expect them too.

Job searching is easier from a great 4 year program. Not trying to flame, just sharing my experience now having seen job searches of friends and co-residents for 4 years now.

 

[dotcb]

I think there are strong arguments that can be made for a variety of paths - 3 year, 3 + fellowship, 4 year, 4 + fellowship. Ultimately I think it will come down to your personal values, program feel, geography, and "fit."

My experience: Did a 4 year program and work in academics. I looked at 3, 4, and EM/IM programs. I ranked a mixture of all 3. Ultimately my top choices were all programs that I thought would provide me the best EM training available, in cities where I want to live. Yes, there were times when I wished I'd done 3 years or 3 + fellowship. But when I look back, there's no question I'm a better doctor, better educator, more academically productive, and wouldn't have gotten my job without doing what I did. Ultimately I'm satisfied with my choice, but each person should choose what seems right to them.

 

[Cerberus]

As a resident in a 4 year program, I object to your choice of words here. The places that have 4 year programs are the places with an interest in providing something more than just emergency medicine training. While I'm sure that 3 year programs produce perfectly adequate emergency medicine physicians, there's not a lot of time in a 3 year residency to develop a niche within emergency medicine. And while yes, everyone likes to say that 3 years + fellowship is more valued than 4 years of EM residency, the truth is that residents from 4 year programs go on to fellowship at much high rates.

I take exception to your implication that 3yr programs don't provide anything beyond "emergency medicine training". My 3yr program offers:

- a SIM position for third years who are interested.
- tons of ultrasound and lots of opportunities for research in that department
- a "teaching resident" position where you work with the med students

It is undoubtedly tighter to get this stuff in than at a 4yr program, but that's not to say it isn't an option. Also, roughly a quarter of our residents generally go on to fellowship (many at 4yr programs). I don't know where you found numbers that 4yr grads are more likely to go on to fellowship than 3yr grads, but if they do, so what? It's not like people from 3yr programs can't do a fellowship, some just choose not to.

Residency, 3yrs or 4 is largely what you make of it. If you are going to do a 4yr, I think it's really important to look at what you will be doing with that extra year, and whether it's worth it to you. There are 4yr programs that offer you niche positions and there are those that just give you extra off-service months. I applied 50-50, and ranked a lot of 4yrs very highly. I am very happy that I ended up at a 3yr program (especially considering I want to do Fellowship and would be less likely to do so had I ended up with an extra year of EM training).

 

[substanceP]

Even though this has been discussed I'm going to bite as a recent 4 year grad.

Emergency med is a 3.5 year residency. People say this as a joke or sort of tongue in cheek but it is true. I think if you do a solid 3 year program you are going to have a few more "oh ****" moments as a junior attendings and if you do a 4 you are going to be a little annoyed towards the end of your 4th year that you are still presenting to an attending.

It is crazy to say that the training is equivalent, it clearly is not, 4 year grads see more. That said 97% of the physician you will be is up to you. The best 3 year grad can hang with any 4 year grad and the worst 4 year grad suck as much as you'd expect them too.

Job searching is easier from a great 4 year program. Not trying to flame, just sharing my experience now having seen job searches of friends and co-residents for 4 years now.

came out of a 4-year program, am one year out. i agree with this post, especially that, "97% of the physician you will be is up to you." i think that should be the take-home point and you should try for the program that is the best personal fit for you, regardless of 3 v 4.

 

[donkeykong1]

apparently all aoa accredited EM programs are 4 years in length because they require an intern year for pgy1 and then you do 3 years of EM. I guess this isn't the case for acgme programs (both 3 and 4). reason why i'm asking is because i've counted a total of 16 EM programs in the state of Ohio. 7 out of the 16 are 4 yr aoa accredited and affiliated with OU

 

[jbar]

It is crazy to say that the training is equivalent, it clearly is not, 4 year grads see more.

I don't know. There are a lot of 4 year programs that do 6 months of non ICU floor work, 4-5 months of ICU, 5 months of electives. Those months have to come from somewhere, months off service are months not in the ER. There are 3 year programs that are spending almost the same number of shifts in the ER as a 4 year program. Now you can argue about the value of those extra rotations, but it's not like the 4 year programs are spending an extra year of ER shifts. Furthermore, it's not just months in the department. There are a lot of other factors. Like resuscitations per month, patients seen per shift, patients with real pathology per shift, ICU admissions per month etc. A resident at a 3 year program that sees high volume, high acuity is going to be just as good as a 4 year program where you are dealing with shananigans all day.

I'm not being defensive about my 3 year program. I agree with other posters, it should be 3.5 years. I'd love an extra month in the unit and an extra month of electives. But I'm happy with my choice, even though I can see the other side of the argument. But you should distrust anyone who says "my way is the only right way to train." Clearly someone with a closed mind.

Keep in mind everyone is talking out of their butts with all this stuff. It's not like someone did a study and proved what the ideal length of training is. Everyone just wants to think they their residency is the best (if it weren't, why would you have ranked it so highly?) I do think it's a bit crazy that we are the only field where there are different length residencies. It's not like you can do a 3 year peds residency or a 4 year one.

 

[13770]

I love this thread. It's always so fun.

The money makes a very big difference.

"Choosing" a 4 year program is lost revenue to the tune of 200,00.00. That's the difference in salary for that one year. If you can find a 4th year that gives you 200k worth, then rock on and go for it. And yes, that would be pre-tax revenue for those of you counting.

As to the altruistic programs that stand on their ideals for a 4th year resident? sure that's out there. But make no mistake, having 12 4th year residents is a very fine budget advantage to the conservative estimate of 2 million a year, and more realistic 2.5 million. And that's lots of reasons to have a 4 year program instead of 3. Now, does that matter to the resident? Well no, but it sure matters to the hospital.

I'm sure someone will argue to the math, so let's crunch it:
4th year resident works 10hr shifts x 18 per month x 6 months (we'll say they're on electives for 6 months for fun). 1080 clinical hours for the year. Salary = 55k, workforce cost with 12 residents 660,000.00. Clinical hours = 12,960 clinical hours.

Replace with attending in an academic shop: 1200 clinical hour per year at Salary of 250k. 12,960 clinical hours at 1200 hrs per doc renders 10.8 docs. These docs at a cost differential of 200k = 2.1 million reasons to have a 4th year for an institution.

Don't confuse institutional finances with residency choices. Pick the residency that you like the most and who cares if it's an extra year? as long as it is the place you love and believe will train you the best.

 

[iridesingltrack]

I love this thread. It's always so fun.

The money makes a very big difference.

"Choosing" a 4 year program is lost revenue to the tune of 200,00.00. That's the difference in salary for that one year. If you can find a 4th year that gives you 200k worth, then rock on and go for it. And yes, that would be pre-tax revenue for those of you counting.

As to the altruistic programs that stand on their ideals for a 4th year resident? sure that's out there. But make no mistake, having 12 4th year residents is a very fine budget advantage to the conservative estimate of 2 million a year, and more realistic 2.5 million. And that's lots of reasons to have a 4 year program instead of 3. Now, does that matter to the resident? Well no, but it sure matters to the hospital.

I'm sure someone will argue to the math, so let's crunch it:
4th year resident works 10hr shifts x 18 per month x 6 months (we'll say they're on electives for 6 months for fun). 1080 clinical hours for the year. Salary = 55k, workforce cost with 12 residents 660,000.00. Clinical hours = 12,960 clinical hours.

Replace with attending in an academic shop: 1200 clinical hour per year at Salary of 250k. 12,960 clinical hours at 1200 hrs per doc renders 10.8 docs. These docs at a cost differential of 200k = 2.1 million reasons to have a 4th year for an institution.

Don't confuse institutional finances with residency choices. Pick the residency that you like the most and who cares if it's an extra year? as long as it is the place you love and believe will train you the best.

It is actually quite expensive for a program to have fourth year EM residents as the federal government provides no assistance. The GME dollars for EM stop after year three. Programs with a four year residency lay out the money from their own coffers. So, if a program wanted more cheap labor why wouldn't they just increase the compliment of a three year program? Furthermore, I doubt sincerely that any program that reliably fills its spots is just riding the backs of their residents work. That is an unsustainable, self-limiting educational model as people would report this commonly on interviews to applicants. If this has been your experience I am truly sorry as you have been robbed.

Iride

 

[TonyC219]

apparently all aoa accredited EM programs are 4 years in length because they require an intern year for pgy1 and then you do 3 years of EM. I guess this isn't the case for acgme programs (both 3 and 4). reason why i'm asking is because i've counted a total of 16 EM programs in the state of Ohio. 7 out of the 16 are 4 yr aoa accredited and affiliated with OU

Just an FYI, most of the DO EM programs (if not all of them) no longer follow the 1 intern year + 3 years of EM model. Now the intern year is linked and is basically a 4 year EM residency. I just finished my intern year and did 7 blocks of EM (we do 4 week rotations at my program). I'm pretty sure this varies by program, but you tend to do more EM than you would with a traditional internship.

 

[nycqqe]

3 years vs 4 years?

It's very simple. Choose a 3 year program that is very strong, with lots of procedures, with very minimal scut work, where you'll spend most of your time seeing high acuity high yield stuff and not where they need a warm body seeing fast tracky stuff and make you feel like you got to pay your dues before you get to see interesting patients. Yes such programs do exist. I trained at one.

Do not waste an extra year if you can get similar training or even better training at a 3 year program. Do not choose a 4 year program just because of the name/prestiege or because they tell you you need more training or electives or "specialty tracks. If that were true, then many programs would be 5 or 6 years. If you really need more training, do a fellwopship. It's that simple.

If a program tells you they prepare you extremely well in 4 years, that's because you really need 4 years in such programs and if you pay a little more attention, you can easily find 3 year programs that do the same or more.

Look past the fluff. Or you will hate yourself when you're a 4th year resident and your friends are in fellowships or are attendings.

 

[Old_Mil]

Private World: Some people say otherwise, but I have talked to enough people that do actual hirings, and they have all told me if given the choice between two applicants, the 4 year graduate with moonlighting experience is typically the most desirable person. IN reality, all of us can find some sort of job somewhere simply by being BE/BC.

Actually, bringing up moonlighting experience is important. Programs vary widely in the amount they let you moonlight. Moonlighting is the one thing I saw consistently mentioned during my job interviews as something employers looked for to prove that you could actually do the job outside of a residency environment.

Going to a program that has significant restrictions on the number of shifts, shift length, and geography of where you can moonlight really cuts down the opportunities residents have to work and bolster their resume as seniors.

This probably is a bigger factor than three vs four years unless you are going into academics.

 

[turkeyjerky]

3 years vs 4 years?

It's very simple. Choose a 3 year program that is very strong, with lots of procedures, with very minimal scut work, where you'll spend most of your time seeing high acuity high yield stuff and not where they need a warm body seeing fast tracky stuff and make you feel like you got to pay your dues before you get to see interesting patients. Yes such programs do exist. I trained at one.

Do not waste an extra year if you can get similar training or even better training at a 3 year program. Do not choose a 4 year program just because of the name/prestiege or because they tell you you need more training or electives or "specialty tracks. If that were true, then many programs would be 5 or 6 years. If you really need more training, do a fellwopship. It's that simple.

If a program tells you they prepare you extremely well in 4 years, that's because you really need 4 years in such programs and if you pay a little more attention, you can easily find 3 year programs that do the same or more.

Look past the fluff. Or you will hate yourself when you're a 4th year resident and your friends are in fellowships or are attendings.

That's really fantastic advice--unfortunately it's also very difficult to follow. Information like that just isn't available to applicants. Most residencies don't release procedure logs (probably of questionable accuracy a lot of the time anyway), people aren't honest to applicants about their own programs' shortcomings, and on an anonymous online forum people get shouted down if they dare to ask such questions.

 

[8654Marine]

Hmm, how does one define scut work?

 

[danzman]

That's really fantastic advice--unfortunately it's also very difficult to follow. Information like that just isn't available to applicants. Most residencies don't release procedure logs (probably of questionable accuracy a lot of the time anyway), people aren't honest to applicants about their own programs' shortcomings, and on an anonymous online forum people get shouted down if they dare to ask such questions.

I agree.

The nature of the match limits the amount of information one can obtain about a program and certainly how one can use said info to influence their actual match. After about 10 interviews I found that all the programs seemed to blend together. I have nothing more to offer on the pro's and con's of a 3/4 yr program than what has been stated, but I will say that many of my buddies would have rather gone to a 4yr EM program than having to scramble into a crappy FM program in the sticks.

For my money, moonlighting opportunities were more important than 3/4.

 

[gro2001]

I think most everyone agrees that 3 and 4 year programs provide a similar quality of training, especially since such a large part of it depends on what you take out of it. A lot of your particular program's deficiencies you can make up for by going the extra mile yourself. What you can't make up or change is how well you fit in with the people around you. Go for a program where you 'click' with the residents and faculty, regardless of 3 vs 4 or almost any other factor. In the end, the 'atmosphere' of the place is what will make the experience either unbearable or fantastic.

 

[EM_Rebuilder]

I love this thread. It's always so fun.

The money makes a very big difference.

"Choosing" a 4 year program is lost revenue to the tune of 200,00.00. That's the difference in salary for that one year. If you can find a 4th year that gives you 200k worth, then rock on and go for it. And yes, that would be pre-tax revenue for those of you counting.
As to the altruistic programs that stand on their ideals for a 4th year resident? sure that's out there. But make no mistake, having 12 4th year residents is a very fine budget advantage to the conservative estimate of 2 million a year, and more realistic 2.5 million. And that's lots of reasons to have a 4 year program instead of 3. Now, does that matter to the resident? Well no, but it sure matters to the hospital.

I'm sure someone will argue to the math, so let's crunch it:
4th year resident works 10hr shifts x 18 per month x 6 months (we'll say they're on electives for 6 months for fun). 1080 clinical hours for the year. Salary = 55k, workforce cost with 12 residents 660,000.00. Clinical hours = 12,960 clinical hours.

Replace with attending in an academic shop: 1200 clinical hour per year at Salary of 250k. 12,960 clinical hours at 1200 hrs per doc renders 10.8 docs. These docs at a cost differential of 200k = 2.1 million reasons to have a 4th year for an institution.

Don't confuse institutional finances with residency choices. Pick the residency that you like the most and who cares if it's an extra year? as long as it is the place you love and believe will train you the best.

As an FYI.. I went to a four year program and made >200,000K my last year... and about half that my third year. I essentially paid off my student loans with my moonlighting money.

The South is the money making capitol of the US for Emergency Medicine... That was certainly the Golden Goose we had! I still miss those days at times...

 

[jbar]

As an FYI.. I went to a four year program and made >200,000K my last year... and about half that my third year. I essentially paid off my student loans with my moonlighting money.

The South is the money making capitol of the US for Emergency Medicine... That was certainly the Golden Goose we had! I still miss those days at times...

That's fine, but I don't think that should be the expectation of an applicant. Most people aren't able to do that. You can also argue that if that value of 4 year program is doing things like electives or persuing your interests, if you spend your free time moonlighting why not just go to a 3 year program and then work clinically the 4th year? It seems to sort of cancel out the advantage of a 4th year, which I see as the ability to do research or spend extra time teaching etc.

 

[Arcan57]

3 years vs 4 years?

It's very simple. Choose a 3 year program that is very strong, with lots of procedures, with very minimal scut work, where you'll spend most of your time seeing high acuity high yield stuff and not where they need a warm body seeing fast tracky stuff and make you feel like you got to pay your dues before you get to see interesting patients. Yes such programs do exist. I trained at one.

Do not waste an extra year if you can get similar training or even better training at a 3 year program. Do not choose a 4 year program just because of the name/prestiege or because they tell you you need more training or electives or "specialty tracks. If that were true, then many programs would be 5 or 6 years. If you really need more training, do a fellwopship. It's that simple.

If a program tells you they prepare you extremely well in 4 years, that's because you really need 4 years in such programs and if you pay a little more attention, you can easily find 3 year programs that do the same or more.

Look past the fluff. Or you will hate yourself when you're a 4th year resident and your friends are in fellowships or are attendings.

Disagree with your position on fast-track (also on graduated responsibility but I'm not addressing that here).

First, fast-track patients are a high percentage of what many EPs see once they graduate. The skills to do well with Level 4 and 5s don't have a lot of cross-over with the critical care, resuscitation skills that we all like to think is what we do for a living. If you're program doesn't have regular exposure to fast-track patients (either in the main ED or 1-2 shifts/month in the fast-track), then it's going to be a struggle when you graduate until you figure them out.

It's far less sexy then knowing how to resurrect a patient in septic shock or optimizing ventilator settings for a patient with ICH, but how you deal with low acuity patients largely determines how successful you are as an EP. The people holding the contracts expect an EP will deal appropriately with emergencies. It's how efficient they are at moving the meat and not generating patient complaints that drives who makes partner or who is given the opportunity to succeed somewhere else.

The lack of understanding of this concept is a major driver in the high turnover among recent grads. Sure, most EPs figure it out but not before the well has been poisoned at their first job.

 

[tkim]

It's how efficient they are at moving the meat and not generating patient complaints that drives who makes partner or who is given the opportunity to succeed somewhere else.

The lack of understanding of this concept is a major driver in the high turnover among recent grads. Sure, most EPs figure it out but not before the well has been poisoned at their first job.

 

[nycqqe]

Disagree with your position on fast-track (also on graduated responsibility but I'm not addressing that here).

First, fast-track patients are a high percentage of what many EPs see once they graduate. The skills to do well with Level 4 and 5s don't have a lot of cross-over with the critical care, resuscitation skills that we all like to think is what we do for a living. If you're program doesn't have regular exposure to fast-track patients (either in the main ED or 1-2 shifts/month in the fast-track), then it's going to be a struggle when you graduate until you figure them out.

It's far less sexy then knowing how to resurrect a patient in septic shock or optimizing ventilator settings for a patient with ICH, but how you deal with low acuity patients largely determines how successful you are as an EP. The people holding the contracts expect an EP will deal appropriately with emergencies. It's how efficient they are at moving the meat and not generating patient complaints that drives who makes partner or who is given the opportunity to succeed somewhere else.

The lack of understanding of this concept is a major driver in the high turnover among recent grads. Sure, most EPs figure it out but not before the well has been poisoned at their first job.

I agree fast track is what most EPs do most of the time, and it's very important because of that and I agree EPs and applicants going into EM need to have a realistic understanding of what EM is mostly about.

I just don't think that's what residents need to spend a disproportionate time learning. That's not the difficult stuff about EM. You don't need to see that many lacerations or URIs to move those meat. But you need to learn to be comfortable with sick after sick after sick in order to move that kind of meat at the same time moving lacs and URIs. Most of the fast track stuff really can even be learened on the job as a 1st year attending, when people are being paid as an attending to see them.

I believe all programs will provide enough fast track exposure, some a lot more. I also believe some programs over emphasize the importance of certain parts of training to impressionable applicants because they need warm bodies to do the work, even better for an extra year. I don't believe all programs provide equal expoure to sick patients and procedures, some more, some less. When a resident only has 3 or 4 years of training, my advice is for people to seek out programs that give them the best bang for their buck, not programs that offer them name, "more" training, more fluff. If people really want "more", do a fellowship and get compensated accordingly.

 

[Arcan57]

I agree fast track is what most EPs do most of the time, and it's very important because of that and I agree EPs and applicants going into EM need to have a realistic understanding of what EM is mostly about.

I just don't think that's what residents need to spend a disproportionate time learning. That's not the difficult stuff about EM. You don't need to see that many lacerations or URIs to move those meat. But you need to learn to be comfortable with sick after sick after sick in order to move that kind of meat at the same time moving lacs and URIs. Most of the fast track stuff really can even be learened on the job as a 1st year attending, when people are being paid as an attending to see them.

It can be learned on the job (and frequently is), but nobody's going to tell you as a new attending that you're f"*ng up a case until after the pooch can't be unscrewed. It's also easy to pick up bad habits as an over-response to criticism. "The director called me out because a patient complained I didn't give them abx for their URI, so now I'm going to give everyone that wanders in a Z-pack."

It's more difficult to pick up subtleties as an attending, because of an almost universal lack of useful feedback. This is compensated for by a large n once you've been an attending for a while, but early on it can be quite disruptive to your career.

Scut (drawing blood, having to routinely start PIVs, wheeling patients to and from the scanner when they aren't critical, splinting once you've done a dozen or so of each type) isn't useful and shouldn't play a large role in training. The vast majority of programs are going to have sufficient volumes of critically ill patients that you're going to learn the "bread and butter" resuscitations.

 

[la gringa]

arcan, your points hit home 100%. i trained in a public hospital and even at our "community" sites, the issues of flow/PG/metrics were not even mentioned. the flow at our main site was so flawed that you could never really tell how fast you were. you had to provide so much primary care that it was hard to "run" much of anything at times.

i got absolutely invaluable training at my 4 year program, and i have absolutely never struggled with "the practice of EM as an attending, but all of those things you don't learn for an exam are absolutely the things with which i have had some issues. however, i sense that those issues aren't taught well at many residency programs... not really a 3 vs 4 issue. i'd be hard pressed to say that more than half of our faculty would be able to function as community docs, either for speed or patient satisfaction or both. when most of us are going to practice in the community, this is a bit of a disservice... whether said expectations are right or wrong, they are what they are!!!

and agree w/ whoever said EM is a 3.5 yr program, that puts it well!

 

[Arcan57]

arcan, your points hit home 100%. i trained in a public hospital and even at our "community" sites, the issues of flow/PG/metrics were not even mentioned. the flow at our main site was so flawed that you could never really tell how fast you were. you had to provide so much primary care that it was hard to "run" much of anything at times.

i got absolutely invaluable training at my 4 year program, and i have absolutely never struggled with "the practice of EM as an attending, but all of those things you don't learn for an exam are absolutely the things with which i have had some issues. however, i sense that those issues aren't taught well at many residency programs... not really a 3 vs 4 issue. i'd be hard pressed to say that more than half of our faculty would be able to function as community docs, either for speed or patient satisfaction or both. when most of us are going to practice in the community, this is a bit of a disservice... whether said expectations are right or wrong, they are what they are!!!

and agree w/ whoever said EM is a 3.5 yr program, that puts it well!

That was the deceptive thing about residency, especially 3rd year. You'd bust your ass, send a half dozen patients to the unit, not have time to document, eat, or pee, and felt like you were seeing 3 patients/hr. Then you'd actually count them up and realize that you were seeing ~1.4 pts/hr. You'd just had the same 8 pts that came in within a half hour of each other for the last 6 hrs. You'd maybe move a fast-track patient through quickly, but they'd be replaced by someone with another 6 hour work-up. Add time waiting for your trauma and surgical consults to make their way up the chain of command (they usually sent someone to see the patient quickly, but actually getting a decision took hours in the not critically ill), and most of us probably never had a month in residency were we averaged 2 pts/hr.

I agree with you that this isn't necessarily a 3 vs. 4 thing, but it's something that most programs don't have time or the practice environment to teach. I'd say about a quarter of my attendings wouldn't hack it outside of academics, but that was mainly due to most of them pulling some absolutely brutal shifts (25 in the lobby and being single coverage on overnights being not uncommon) at our two community shops.

42 months sounds about right in my mind as an optimum training length, with mandatory moonlighting the last 6 months. Also, the RRC should mandate some kind of metric/pt sat education in the last year of residency. I know I made it through residency having exactly 1 month were I had an accurate count of how many patients I saw. I never saw any info on LOS, door-to-doc, or patient sat scores despite these being the numbers that determine whether I get a bonus (or get to stay working at my current location).

 

[la gringa]

That was the deceptive thing about residency, especially 3rd year. You'd bust your ass, send a half dozen patients to the unit, not have time to document, eat, or pee, and felt like you were seeing 3 patients/hr. Then you'd actually count them up and realize that you were seeing ~1.4 pts/hr. You'd just had the same 8 pts that came in within a half hour of each other for the last 6 hrs. You'd maybe move a fast-track patient through quickly, but they'd be replaced by someone with another 6 hour work-up. Add time waiting for your trauma and surgical consults to make their way up the chain of command (they usually sent someone to see the patient quickly, but actually getting a decision took hours in the not critically ill), and most of us probably never had a month in residency were we averaged 2 pts/hr.

I agree with you that this isn't necessarily a 3 vs. 4 thing, but it's something that most programs don't have time or the practice environment to teach. I'd say about a quarter of my attendings wouldn't hack it outside of academics, but that was mainly due to most of them pulling some absolutely brutal shifts (25 in the lobby and being single coverage on overnights being not uncommon) at our two community shops.

42 months sounds about right in my mind as an optimum training length, with mandatory moonlighting the last 6 months. Also, the RRC should mandate some kind of metric/pt sat education in the last year of residency. I know I made it through residency having exactly 1 month were I had an accurate count of how many patients I saw. I never saw any info on LOS, door-to-doc, or patient sat scores despite these being the numbers that determine whether I get a bonus (or get to stay working at my current location).

i never had a count, period. even at the community spots... one of which was a hospital to which i wouldn't send an enemy and the other has turned over groups at least 3x in the last 5 yrs. door to dispo in less than 3 hrs, or even less than that at my prior gig? ha, never. there was one attending who handled complaints, but i never knew what came of those... as far as i know, i had zero... but that isn't realistic for 3 yrs of EM!!

we weren't allowed to moonlight in any meaningful fashion - not sure any of the programs in my city did though. it was all very very supervised or not EM at all.

sigh. the things i would have done differently if i knew as a 4th yr med student if i knew then what i know now! (and not doing EM wouldn't be the "different" thing... i would have taken a different approach to residency entirely)

 

[Arcan57]

i never had a count, period. even at the community spots... one of which was a hospital to which i wouldn't send an enemy and the other has turned over groups at least 3x in the last 5 yrs. door to dispo in less than 3 hrs, or even less than that at my prior gig? ha, never. there was one attending who handled complaints, but i never knew what came of those... as far as i know, i had zero... but that isn't realistic for 3 yrs of EM!!

we weren't allowed to moonlight in any meaningful fashion - not sure any of the programs in my city did though. it was all very very supervised or not EM at all.

sigh. the things i would have done differently if i knew as a 4th yr med student if i knew then what i know now! (and not doing EM wouldn't be the "different" thing... i would have taken a different approach to residency entirely)

One of the things I think helped me out was getting involved in the administrative aspect early out of residency. I had thought I was going to do academics until my wife matched for fellowship in a city without an EM program, and hadn't paid much attention to metrics/flow/PG (MFP?) in residency. If you're viewing community EM as a career (and not just a way to fund vacations or family life), consider early on going for an assistant director position or at least sitting on one of the ED leadership committees. Even if you have no intention of becoming an administrator, learning the language and basics of why things work like they do at your shop will increase your job satisfaction in the future. If you want, look at it like a really well paying fellowship in community EM (which could be a thing now that I think about it). There's usually a modest increase in pay and if you're with a contract management group there's usually at least yearly paid travel to a variety of 2nd tier cities for leadership seminars, etc.

 

[AmoryBlaine]

That was the deceptive thing about residency, especially 3rd year. You'd bust your ass, send a half dozen patients to the unit, not have time to document, eat, or pee, and felt like you were seeing 3 patients/hr. Then you'd actually count them up and realize that you were seeing ~1.4 pts/hr. You'd just had the same 8 pts that came in within a half hour of each other for the last 6 hrs. You'd maybe move a fast-track patient through quickly, but they'd be replaced by someone with another 6 hour work-up. Add time waiting for your trauma and surgical consults to make their way up the chain of command (they usually sent someone to see the patient quickly, but actually getting a decision took hours in the not critically ill), and most of us probably never had a month in residency were we averaged 2 pts/hr.

Arcan is dropping gold all over this thread...

This is something I noticed in my senior years of residency. You would feel like you hadn't sat down and then when you ran your numbers it was 1.8/hr.

Some of that though is just that staff at a residency training program tend to be incredibly lazy and entitled. We rarely had anyone even do pages for us so I would often spend up to a 45-1 hour of my shift on the phone with answering services. At my attending gig the unit secretaries expect to do this work. When I have a minor procedure it is set up for me, etc. Lots of things are done to maximize the time you spend practicing medicine.

 

[AmoryBlaine]

I don't know. There are a lot of 4 year programs that do 6 months of non ICU floor work, 4-5 months of ICU, 5 months of electives. Those months have to come from somewhere, months off service are months not in the ER. There are 3 year programs that are spending almost the same number of shifts in the ER as a 4 year program. Now you can argue about the value of those extra rotations, but it's not like the 4 year programs are spending an extra year of ER shifts. Furthermore, it's not just months in the department. There are a lot of other factors. Like resuscitations per month, patients seen per shift, patients with real pathology per shift, ICU admissions per month etc. A resident at a 3 year program that sees high volume, high acuity is going to be just as good as a 4 year program where you are dealing with shananigans all day.

True, although in my n=1 study I have never met a 3 year grad with anything close to my 4 year procedural/resus experience.

 

[AmoryBlaine]

I love this thread. It's always so fun.

The money makes a very big difference.

"Choosing" a 4 year program is lost revenue to the tune of 200,00.00. That's the difference in salary for that one year. If you can find a 4th year that gives you 200k worth, then rock on and go for it. And yes, that would be pre-tax revenue for those of you counting.

This is true there is no question. I just got done making 25% of what I make as an attending and my loans capitalized another year of interest.

But I think you can argue this both ways. I look at my medical career as (hopefully) 30 years of relative peace and satisfaction. I think going to a great 4 year program I have maximized my changes of having those things. I have a friend who went to a decent 3 year program and just took a **** job at a **** hospital. Yeah, he is making money sooner than I did but clearly this is not the kind of place where he can be for 30 years and be happy. He already has major second thoughts about his work choice.

This is all speculative though. The study would be to survey 3 and 4 year grads who are 20 years out and see if there is a difference in satisfaction, income then, etc.

 

[Xerxes1729]

Also, the RRC should mandate some kind of metric/pt sat education in the last year of residency. I know I made it through residency having exactly 1 month were I had an accurate count of how many patients I saw. I never saw any info on LOS, door-to-doc, or patient sat scores despite these being the numbers that determine whether I get a bonus (or get to stay working at my current location).

This varies by program. At our primary site, I can view my patient list for every shift I've ever worked. I can see patients per shift, door-to-disposition time, etc. Our PD presents us biannually with our patients per hour and patient satisfaction scores and a (deindentified) plot of where we stand relative to the rest of our PGY class. It helps that we have an outstanding IT infrastructure that allows us to capture all this data.

 

[Arcan57]

This varies by program. At our primary site, I can view my patient list for every shift I've ever worked. I can see patients per shift, door-to-disposition time, etc. Our PD presents us biannually with our patients per hour and patient satisfaction scores and a (deindentified) plot of where we stand relative to the rest of our PGY class. It helps that we have an outstanding IT infrastructure that allows us to capture all this data.

This.

 

[jbar]

As to the Fast track thing, I had thought going into residency I would want some dedicated fast track experience. But I've found that since our fast track closes at 10pm, on the overnight shift I'm getting plenty of fast track type patients.

 

[alexandertg6]

Oops