Best Chicago Program

[BKN]

To respond to your assumption that all the programs in chicago (or at least the 3 programs you mention) see the same level of acuity, here is the info posted on the SAEM website. I think this shows that there is a pretty drastic difference, which I also felt was apparent when I observed in the various ER's.

Hospital ----------- Volume/year ---- Admission rate ---- % admit to ICU ----
Univ. of Chicago ----- 80,000 ------------- 25% ----------------- 33%
Cook County ------- >125,000 ------------ 21% ----------------- 25%
Christ ----------------55,000 ------------- 29% ----------------- 18%
Northwestern -------- 74,000 ------------- 28% ----------------- 15%
UIC ------------------ 52,000 ------------- 20% ---------------- 10%
Ressurection --------- 37,000 ------------- 27% ----------------- 5%

The average % admit rate to the ICU is about 10-15%. Many of the community hospitals have an ICU admit rate of <5%. The University of Chicago is only topped by UCLA Harbor (#1), and the University of Florida--Jacksonville (#2) in % of patients admitted to the ICU, both of which are inner city county programs.

Boy there's nothing I like better than an argument about statistics! You'all have pointed out most of the problems with the admission tables, but there's one more that I didn't notice mentioned in a quick read.

The format says Admissions (% of visits) and ICU admissions (% of admissions). The info in the SAEM catalog is program supplied and is frequently misstated. Often programs state the ICU admits as % of visits, since that's how the RRC used to ask for it. Looking at the data above I'm pretty sure that U of C and Cook did it right, Resurrection did it wrong and I'm not sure about the three in the middle. I'm pretty sure that the Resurrection line should read: admission rate 27%, ICU admission rate 18.5% (5/27). That would put it in the general range of the others.

Given all of the things that can affect these numbers (Attendings seeing patients, rotators, mid-levels, fast-tracks etc), it's hard to compare them. I can tell you what I understand the RRC used a few years ago as flags for minimums:

Admissions: <15%
ICU admissions: <3%
Visits/resident/year: <2000 (also >3000 might be too much).

Given the changes in acuity and managed care and the tearing of the safety net, all EDs are becoming more like the publics. A much higher percentage of admissions are ICU admits than in the past. Volume is increasing everywhere and much more workup is done on each patient before admission decisions. I'm not sure that the guidelines above still have much relevance.

A final thought. Some of the posts refer to fast tracks and midlevels making it harder to compare the numbers. Very true, but is that a bad thing for training? I'd say not. If you see a higher portion of sicker patients in your training and have more time to work on them, I think your training is enriched. You only have to see so many colds before you can differentiate them successfully from pneumonia.

cheers.

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[placebo_B12]

The format says Admissions (% of visits) and ICU admissions (% of admissions). The info in the SAEM catalog is program supplied and is frequently misstated. Often programs state the ICU admits as % of visits, since that's how the RRC used to ask for it. Looking at the data above I'm pretty sure that U of C and Cook did it right, Resurrection did it wrong and I'm not sure about the three in the middle. I'm pretty sure that the Resurrection line should read: admission rate 27%, ICU admission rate 18.5% (5/27). That would put it in the general range of the others.

I guess it is conceivable that Ressurection got it wrong, but they are very much like a community hospital from what I understand. Their profile on EMRA was just updated 1 year ago.

On the other hand, I don't buy that the middle 3 may have got it wrong. If what you're saying was right than Northwestern, UIC, and Christ would have 55-70% admit rates to the ICU (I highly doubt that). That would mean that they admit TWICE as many patients to the ICU than all of the floor services combined (general medicine, gen surg, ortho, neurology, psych, telemetry, step-down, pediatrics, labor and delivery). It would also mean that they have the top 3 highest acuity ER's in the country. For some reason, I'm not buying it.

 

[rxfudd]

I guess it is conceivable that Ressurection got it wrong, but they are very much like a community hospital from what I understand.

Having rotated at Res, I want to point out that they have an unbelievably high acuity. I was seriously impressed with the pathology they get there - we frequently had multiple pts going to the ICU in a given day. Looking at those numbers, I'd have to go with what BKN is proposing. There is no way they only have 5% ICU admissions per total visits.

 

[BKN]

Having rotated at Res, I want to point out that they have an unbelievably high acuity. I was seriously impressed with the pathology they get there - we frequently had multiple pts going to the ICU in a given day. Looking at those numbers, I'd have to go with what BKN is proposing. There is no way they only have 5% ICU admissions per total visits.

Actually I was saying 5% per total visits, 18.5% of total admissions. The SAEM site asks for % of admissions, but the RRC criteria was % of total visits, thus the confusion.

 

[rxfudd]

Actually I was saying 5% per total visits, 18.5% of total admissions. The SAEM site asks for % of admissions, but the RRC criteria was % of total visits, thus the confusion.

Right, that was my fault - meant to say that there is no way Res only has 5% ICU admissions per total admissions.

 

[BKN]

I guess it is conceivable that Ressurection got it wrong, but they are very much like a community hospital from what I understand. Their profile on EMRA was just updated 1 year ago.

On the other hand, I don't buy that the middle 3 may have got it wrong. If what you're saying was right than Northwestern, UIC, and Christ would have 55-70% admit rates to the ICU (I highly doubt that). That would mean that they admit TWICE as many patients to the ICU than all of the floor services combined (general medicine, gen surg, ortho, neurology, psych, telemetry, step-down, pediatrics, labor and delivery). It would also mean that they have the top 3 highest acuity ER's in the country. For some reason, I'm not buying it.

Actually 30-60% of admissions to units (if you include telemetry) from the ED is entirely possible in 2006. That was the point of the second to last paragraph of the post. Think about it, in a strongly managed care enviroment with an efficient hospital:
1. elective surgery is not admitted from the ED, and often is done as an outpatient in a surgicenter or an MDs office. The plastic surgeons, ENTs, and many of the ortho guys often aren't even on hospital staff anymore.
2. Medical, pediatric and OB patients are most often admitted directy. Others that would have been admitted 10 years ago are treated as outpatients (e.g. many pneumonias, much DVT, cancer chemo, etc)

The reason is that hospitals have priced themselves out of much of the business where there are alternatives. Hospitals have huge fixed costs (bricks and mortar, 24/7 staffing and yes the uninsured in the ED).

So the ED have become the big diagnostic centers and most of the rest of the hospital is special care units with ICU beds a much greater proportion than in the past.

 

[r54918]

Actually 30-60% of admissions to units (if you include telemetry) from the ED is entirely possible in 2006.

Telemetry is NOT an ICU bed. I don't know anybody who would even consider those 2 things in the same realm. Telemetry is a floor bed with a monitor--that's it. These people are STABLE. ICU entails 1 nurse per every 2 patients, and patients must be UNSTABLE by definition. Totally different.

Telemetry pt -- brief syncopal episode, pt is talking and making jokes
ICU pt -- Septic, hypotensive, ARDS, on pressors, intubated on a ventillator

 

[FoughtFyr]

Telemetry is NOT an ICU bed. I don't know anybody who would even consider those 2 things in the same realm.

Umm, you do realize that BKN is a program director right? I think, given his experience and position, he is allowed to say what is and is not relevant to a resident's education.

Second, you obviously are not widely experienced in health care. There are many institutions where an ICU is the only monitored bed (or there might be limited monitored beds outside of ICUs). In those places "ICU admits" means something more akin to "telemetry admits" in others. I think this is why BKN drew this comparison.

- H

 

[FoughtFyr]

I can tell you what I understand the RRC used a few years ago as flags for minimums:

Admissions: <15%
ICU admissions: <3%
Visits/resident/year: <2000 (also >3000 might be too much).

O.k., let's dissect. If we take a senior resident, for the sake of example, at 10 months in the ED (40 weeks) per year. And lets assume a 50 hr average work week (in the ED) - again, this is for example. So, an EM senior works 2000 hrs in the ED. So, <2000 would be less than 1.0 pph. Ouch. But >3000 as too much? I would think >6000 before real pain sets in. And again, the measure should be (IMNSHO) Visits/sum total (average number of residents both EM and off service residents in the department each month) + (number of midlevel providers in the department)/year.

- H

 

[BKN]

O.k., let's dissect. If we take a senior resident, for the sake of example, at 10 months in the ED (40 weeks) per year. And lets assume a 50 hr average work week (in the ED) - again, this is for example. So, an EM senior works 2000 hrs in the ED. So, <2000 would be less than 1.0 pph. Ouch. But >3000 as too much? I would think >6000 before real pain sets in. And again, the measure should be (IMNSHO) Visits/sum total (average number of residents both EM and off service residents in the department each month) + (number of midlevel providers in the department)/year.

- H

You forgot that the EM senior is only on service about half the year, try 7 months/yr * 4.2 weeks/month * 50 hr/wk = 1420 hrs/yr. 2000/1420 = 1.4/hr or 3000/1420 = 2.1/hr.

However, lots of other considerations have been brought up already in the thread. Add one other specific, juniors probably work less efficiently, therefore seniors taking up slack.

Like I said, these guidelines were used a while ago, I'm not sure they have anything to do with the way ED patients have gotten more acute and diagnostic efforts have gotten more intense and longer before admission in the last 15 years.

 

[Apollyon]

You forgot that the EM senior is only on service about half the year

What else do your seniors do in the 3rd year? My program is off-service heavy as an intern, then there's 6 months as a 2 (ICU's, trauma, and ortho, and elective), and only 2 months off-service as a senior (elective and EMS). Mostly in the ED as a senior I thought was the status quo.

 

[BKN]

Telemetry is NOT an ICU bed. I don't know anybody who would even consider those 2 things in the same realm. Telemetry is a floor bed with a monitor--that's it. These people are STABLE. ICU entails 1 nurse per every 2 patients, and patients must be UNSTABLE by definition. Totally different.

Telemetry pt -- brief syncopal episode, pt is talking and making jokes
ICU pt -- Septic, hypotensive, ARDS, on pressors, intubated on a ventillator

Gee, thanks for explaining, I was unclear on that concept.

I've been living with these statistics and advising students on how to interpret them for about 25 years. I'm not talking down to you, I'm trying to suggest that they are easily manipuble and not all that useful. I'm not even suggesting that PDs are being dishonest, just that they are confusing and hospital data is often not available in exactly the format that the website requires. Some PDs and hospitals may count the telemetry admissions as critical care admissions others will not.

I see all over SDN a desire to "rate" programs and schools. But a rating program by the powers that be exists. www.acgme.org has the exact accreditation data. All else is opinion.

 

[BKN]

What else do your seniors do in the 3rd year? My program is off-service heavy as an intern, then there's 6 months as a 2 (ICU's, trauma, and ortho, and elective), and only 2 months off-service as a senior (elective and EMS). Mostly in the ED as a senior I thought was the status quo.

I'm not sure that your program is typical. I think most programs are like:
EM1: 4 mo EM2: 7 EM 3: 7.

If you're really interested in our details: http://www.ttuhsc.edu/elpaso/som/em/

cheers

 

[FoughtFyr]

I'm not sure that your program is typical. I think most programs are like:
EM1: 4 mo EM2: 7 EM 3: 7.

If you're really interested in our details: http://www.ttuhsc.edu/elpaso/som/em/

cheers

With all due (and considerable) respect BKN, if you go to the AAEM RSA website these statistics are listed out (months of EM or EM electives by year). At quick glance most programs are ~10 months in the department during PGY-3. The site is here.

Two caveats - first, I am biased towrd this site as I helped develp it, and a listing of these stats was my idea. Second, your program is, apparently, listed inaccurately as it shows 6, 8, and 11 months in PGY 1-3 respectively.

- H

 

[Apollyon]

I'm not sure that your program is typical. I think most programs are like:
EM1: 4 mo EM2: 7 EM 3: 7.

If you're really interested in our details: http://www.ttuhsc.edu/elpaso/som/em/

cheers

Randomly straw-polling 1-3 programs on SAEM reveals 7 months to be on the low side, with an average of 8-9 months (low of 6, high of 11) in the ED (however, the months may be calendar or 4 weeks, which is a confounder).

PS Your name here is spelled wrong

 

[BKN]

Randomly straw-polling 1-3 programs on SAEM reveals 7 months to be on the low side, with an average of 8-9 months (low of 6, high of 11) in the ED (however, the months may be calendar or 4 weeks, which is a confounder).

Interesting. Thanks.

PS Your name here is spelled wrong

and thanks for that as well.

 

[r54918]

Umm, you do realize that BKN is a program director right? I think, given his experience and position, he is allowed to say what is and is not relevant to a resident's education.

While I appreciate the fact that he is a PD, that does not mean that he is the end all be all on any given topic. And it surely doesn't mean that a telemetry bed is equivalent to an ICU bed. I honestly believe that if programs are counting telemetry beds as ICU beds than that is misleading information. Would you disagree????

Second, you obviously are not widely experienced in health care. There are many institutions where an ICU is the only monitored bed (or there might be limited monitored beds outside of ICUs). In those places "ICU admits" means something more akin to "telemetry admits" in others. I think this is why BKN drew this comparison.

- H

You're right... I am a fool when it comes to health care. You are so much smarter than me. Thanks for clarifying that. I'm kidding... lets not turn this into a mudslinging war. But I don't see how you derived that I'm so grossly incompetent from what I've said.

This doesn't make any sense. The types of hospitals that do not have telemetry are smaller community hospitals, and these would be the hospitals with the inflated ICU admit rates b/c stable patients would get admitted to the ICU out of default. All of the hospitals we are talking about are large academic centers, and have telemetry beds as well as ICU. So your point is mute in this case.

 

[r54918]

I've been living with these statistics and advising students on how to interpret them for about 25 years. I'm not talking down to you, I'm trying to suggest that they are easily manipuble and not all that useful. I'm not even suggesting that PDs are being dishonest, just that they are confusing and hospital data is often not available in exactly the format that the website requires. Some PDs and hospitals may count the telemetry admissions as critical care admissions others will not.

I agree... I think all the stats should be interpreted with a grain of salt. But it is still shady to include general telemetry admissions as "critical care" admissions.

 

[corpsmanUP]

Gee, thanks for explaining, I was unclear on that concept.

I was sitting back waiting to see how this reply would go down....almost to the point of ecstatic anticipation. Listen R2D2 or whatever your name is, I humbly suggest you keep it cool before you end up on the PD blacklist listserve Thats no place to be...you do realize your IP address is tracked by the moderators and sent to the Department of Homeland Security quarterly! Lucky for you the DOHS is still waiting for their order of ethernet cables and they are not due to receive them until 2008. You should have matched by then I hope

 

[FoughtFyr]

This doesn't make any sense. The types of hospitals that do not have telemetry are smaller community hospitals, and these would be the hospitals with the inflated ICU admit rates b/c stable patients would get admitted to the ICU out of default. All of the hospitals we are talking about are large academic centers, and have telemetry beds as well as ICU. So your point is mute in this case.

Actually, it is the bigger academic centers that don't have many tele beds. In these institutions strong cardiology programs have kept tele beds out of the hands of "medicine". Thus, OD patients, hyperkalemics, severe elctrolyte disturbances etc may go to MICUs.

The smaller centers have lots of tele beds - they are WAY cheaper than dedicated cardiology units and ICUs.

- H

 

[BKN]

With all due (and considerable) respect BKN, if you go to the AAEM RSA website these statistics are listed out (months of EM or EM electives by year). At quick glance most programs are ~10 months in the department during PGY-3. The site is here.

Two caveats - first, I am biased towrd this site as I helped develp it, and a listing of these stats was my idea. Second, your program is, apparently, listed inaccurately as it shows 6, 8, and 11 months in PGY 1-3 respectively.

- H

Looked at it, very interesting. Maybe I should make the residents work in the ED more. We don't need no stinking ICUs, deliveries, trauma experience etc.

If you got our program's numbers wrong, are your sure that the others are accurate? Perhaps even less reliable than self-reporting a la SAEM catalog is taking the info from somebody else, then not updating it. The links to our website don't work either. The urls listed are several years out of date.

Thanks

edit: FF, something else occurs to me. Perhaps some of the confusion in numbers might have occurred if other department of emergency medicine rotations were counted as emergency department rotations. What I mean is at our place that would add Ped EM, toxicology/research, EMS, and ED admin.

 

[WilcoWorld]

Every year this thread turns sour, and every year I learn something. This year I learned that there are enough jerks to slam each and every Chicago program, that most doctors will interpret the same data differently (OK, I guess I already knew that), and I learned that Fatty McFattypants just doesn't do the trick like it used to.

Fuzzy VonHairyback(???)

 

[WilcoWorld]

I also learned that one shouldn't post after drug rep dinners.

Is it just me, or doth Nesiritide protest too much?

Umm, on second thought, scratch that - please kill this thread.

 

[pinbor1]

I also learned that one shouldn't post after drug rep dinners.

Is it just me, or doth Nesiritide protest too much?

Umm, on second thought, scratch that - please kill this thread.

Wilco

I hear that Fuzzy VonHairyback ,the PD of In N Out's EM residency, is moving their program to Chicago. They will surely be the top program in Chicago.

 

[JackBauERfan]

While I appreciate the fact that he is a PD, that does not mean that he is the end all be all on any given topic. And it surely doesn't mean that a telemetry bed is equivalent to an ICU bed. I honestly believe that if programs are counting telemetry beds as ICU beds than that is misleading information. Would you disagree????


You're right... I am a fool when it comes to health care. You are so much smarter than me. Thanks for clarifying that. I'm kidding... lets not turn this into a mudslinging war. But I don't see how you derived that I'm so grossly incompetent from what I've said.

This doesn't make any sense. The types of hospitals that do not have telemetry are smaller community hospitals, and these would be the hospitals with the inflated ICU admit rates b/c stable patients would get admitted to the ICU out of default. All of the hospitals we are talking about are large academic centers, and have telemetry beds as well as ICU. So your point is mute in this case.

So your point is mute in this case

I think you mean 'moot'....or mute works well in meaning i guess haha.

 

[EctopicFetus]

Wilco

I hear that Fuzzy VonHairyback ,the PD of In N Out's EM residency, is moving their program to Chicago. They will surely be the top program in Chicago.

I am VERY confused.. I thought Dr McFattypants was the PD.. Did something happen to him to let them elevate Dr. Fuzzy VonHairyback from his role as Asst PD?

 

[FoughtFyr]

Looked at it, very interesting. Maybe I should make the residents work in the ED more. We don't need no stinking ICUs, deliveries, trauma experience etc.

I'm not suggesting that at all.

If you got our program's numbers wrong, are your sure that the others are accurate? Perhaps even less reliable than self-reporting a la SAEM catalog is taking the info from somebody else, then not updating it. The links to our website don't work either. The urls listed are several years out of date.

I helped design the site. I am not responsible for it's current content but I will let the powers that be know. The idea was to allow easier "head-to-head" comparisons than the other catalogs.

edit: FF, something else occurs to me. Perhaps some of the confusion in numbers might have occurred if other department of emergency medicine rotations were counted as emergency department rotations. What I mean is at our place that would add Ped EM, toxicology/research, EMS, and ED admin.

That is where the difference is. The heading is "EM or EM electives". It was designed to differentiate those rotations that "pull you from the department" to those "home" rotations. So, yes, the four rotations you mention would be included in the count. To be fair, Ped EM would have to be included in the statistics listed above because the senior is going to see patients on that rotation.

Even with this explanation, I think that most programs (by my memory - interviews were two years ago) are very "straight EM" heavy in the third year. Our program is 10 months (if you count a one month "Community EM" rotation).

- H

 

[BKN]

Thanks, FF.

 

[EctopicFetus]

bump bump bump for the dude..