ACGME proposing changes to EM residency requirements

[Emapp20177]

Basically the people who come on here every day to bitch and moan about the state of EM and the proliferation of bad residencies... are now on here to bitch and moan about the proposed fix for said bad residencies.

Nothing is perfect. There will be unexpected good and bad consequences if this thing passes. I wholeheartedly support it.

Forcing excellent 3 year programs into 4 years does absolutely nothing but harm EM.

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[trackrunner321]

I mean it’s a great way to get out of the PIT. Bunch of protected time. You can still work some clinical shifts.Truth be told if that individual wont take it someone else will. Yeah it’s bad but if the pot is sweet enough anyone in this forum would take it.

How many of these HCA and CMG programs are actually paying enough attendings for educational non-clinical work? I have a hard time believing that many of them are paying for enough non-clinical time given that it would hurt their bottom line.

 

[JacobMcCandles]

And how does one realistically get that done?
These programs are not gonna shutter themselves for ethical reasons.

Realistically? You can't. You've gone from 1607 available positions in 2011 to 2567 in 2020 and I'm sure that's even more now. If you want to do right by the applicants then you'd shut down a lot of these programs so they aren't taking on new residents but let the current residents continue through. The ACGME got themselves into this mess and I doubt they want to make the difficult decisions to get them out of this mess.

 

[EctopicFetus]

How many of these HCA and CMG programs are actually paying enough attendings for educational non-clinical work? I have a hard time believing that many of them are paying for enough non-clinical time given that it would hurt their bottom line.

I mean i dont think there are a ton of spots for those jobs but I also haven't looked. I know some people at an HCA residency and they make about $160-180/hr for non clinical work. I don't know how many hours they get.

 

[EctopicFetus]

No attending should be bitching about this. I can see med students bitching but they have no foresight and a good portion of them don't even know what they're getting themselves into by choosing EM. This is evident by the number of new attendings claiming EM was a mistake. Hopefully it'll help decrease primary care shortages as well.

I hear the argument about NP/PAs getting by with lesser education and working in the ER. Every site I work at, the midlevels are paid less than half of what the attendings are. The midlevels are pushed to see higher volumes of low acuity patients, making our jobs easier. We have an oversupply of midlevels, so those with poor performance/attitudes don't last. The midlevels frankly are keeping me sane by seeing all the pediatric URIs and comforting their obnoxious parents.

Until they miss a bad one and your name is on that chart..

I do agree. As I said I think EM only needs 3 years.. but this is like pulling the ladder up behind us. It doesn't feel good to me but the end result I fully support. I will say no excuses for legacy programs that cant meet the criteria.

 

[EctopicFetus]

Realistically? You can't. You've gone from 1607 available positions in 2011 to 2567 in 2020 and I'm sure that's even more now. If you want to do right by the applicants then you'd shut down a lot of these programs so they aren't taking on new residents but let the current residents continue through. The ACGME got themselves into this mess and I doubt they want to make the difficult decisions to get them out of this mess.

I mean why does the ACGME care? Even funnier is my opinion that ACEP doesn't care in theory about this.. it is more potential ACEP members but the academics including those in acep see their golden goose about to die.. Im sure the rules are set to protect themselves.

A real concern with the ACEP workforce issue is the mismatch for society. Having a bunch of EM docs every year very soon with no job means we wasted the time and money and energy to train something we don't need all while leaving other fields bare.

I do think some of the ACGME requirements are dumb but I don't think it is bad to force a rotation in tox. I feel like IM/Surgery etc all mandate some time in subspecialties. I am uncertain the utility of forcing the docs to work in "low resource" settings. Is this code for rural EM? If they have 60+ weeks of this it seems insane to me. I haven't read the details but hard to justify that. Is it just a move to keep some small one off hospitals to have an EM program?

 

[JacobMcCandles]

I mean why does the ACGME care? Even funnier is my opinion that ACEP doesn't care in theory about this.. it is more potential ACEP members but the academics including those in acep see their golden goose about to die.. Im sure the rules are set to protect themselves.

A real concern with the ACEP workforce issue is the mismatch for society. Having a bunch of EM docs every year very soon with no job means we wasted the time and money and energy to train something we don't need all while leaving other fields bare.

I do think some of the ACGME requirements are dumb but I don't think it is bad to force a rotation in tox. I feel like IM/Surgery etc all mandate some time in subspecialties. I am uncertain the utility of forcing the docs to work in "low resource" settings. Is this code for rural EM? If they have 60+ weeks of this it seems insane to me. I haven't read the details but hard to justify that. Is it just a move to keep some small one off hospitals to have an EM program?

I agree with this. I don't think ACGME cares and, ultimately, I don't think ACEP cares or at least enough to do anything about it. The CMGs certainly would love a glut of EM docs to drive down compensation and make places easier to staff.

I also don't know if doing a bunch of rotations in low resource settings is necessarily beneficial. I think it's more beneficial to work at a place where you see a lot of patients with lots of pathology but you don't consult every specialty for everything.

 

[EctopicFetus]

I agree with this. I don't think ACGME cares and, ultimately, I don't think ACEP cares or at least enough to do anything about it. The CMGs certainly would love a glut of EM docs to drive down compensation and make places easier to staff.

I also don't know if doing a bunch of rotations in low resource settings is necessarily beneficial. I think it's more beneficial to work at a place where you see a lot of patients with lots of pathology but you don't consult every specialty for everything.

Agreed. Maybe thats the intent.. If you train at an ivory tower place and ortho is scouring the board to steal reductions, trauma for chest tubes etc then it makes sense to work at a place with minimal resources. The future is near.. unsure if it will be great but it will be different.

 

[Arcan57]

I also don't know if doing a bunch of rotations in low resource settings is necessarily beneficial. I think it's more beneficial to work at a place where you see a lot of patients with lots of pathology but you don't consult every specialty for everything.

And where does this happen? A place with ortho, optho, hand, etc is going to want its residents doing those procedures. And most academic EM attendings are going to act like having ortho on call means that dealing with a fx/dislocation without ortho's involvement is too medicolegally risky. Only places without regular coverage in those areas are going to give EM residents those procedures outside of a dedicated rotation in that specialty.

I'm willing to bet most "low resource" places aren't going to be no volume CAHs but med/high volume suburban sites with specialists that are used to showing up the next day to a gift wrapped patient. If anyone has their definition of low resource, that'd probably help clarify though.

 

[Zebra Hunter]

Slight tangent, but I think one interesting thing no one is talking about is 2030 we are suddenly going to have a 90% reduction in graduating residents for a single year, as the only residents graduating that year will be those already in 4 year programs.

What’s the current average working life span of a full-time EM doc nowadays? 15-20 years at most?

We are suddenly going to have a ~3-5% reduction in the workforce in a single year, as those leaving EM won’t be replaced for that single year.

 

[JacobMcCandles]

And where does this happen? A place with ortho, optho, hand, etc is going to want its residents doing those procedures. And most academic EM attendings are going to act like having ortho on call means that dealing with a fx/dislocation without ortho's involvement is too medicolegally risky. Only places without regular coverage in those areas are going to give EM residents those procedures outside of a dedicated rotation in that specialty.

I'm willing to bet most "low resource" places aren't going to be no volume CAHs but med/high volume suburban sites with specialists that are used to showing up the next day to a gift wrapped patient. If anyone has their definition of low resource, that'd probably help clarify though.

I trained where there was an active ortho residency and calling them to come down was not routine. Calling someone to come to the ED is definitely a choice as the specialists aren’t trolling your board. An EM attending would be kidding themselves if they think having a 2nd year ortho resident coming down lowers their risk. It’s rare an orthopod does a reduction outside of the OR once they get out of residency anyway so it’s a waste of a reduction to have them do it in the ED.

 

[EctopicFetus]

Slight tangent, but I think one interesting thing no one is talking about is 2030 we are suddenly going to have a 90% reduction in graduating residents for a single year, as the only residents graduating that year will be those already in 4 year programs.

What’s the current average working life span of a full-time EM doc nowadays? 15-20 years at most?

We are suddenly going to have a ~3-5% reduction in the workforce in a single year, as those leaving EM won’t be replaced for that single year.

Agree but by the time that happens we will have 10k too many em docs.

 

[RutgersRah112]

I agree with this. I don't think ACGME cares and, ultimately, I don't think ACEP cares or at least enough to do anything about it. The CMGs certainly would love a glut of EM docs to drive down compensation and make places easier to staff.

I also don't know if doing a bunch of rotations in low resource settings is necessarily beneficial. I think it's more beneficial to work at a place where you see a lot of patients with lots of pathology but you don't consult every specialty for everything.

Agree 100% they do NOT care.

 

[trackrunner321]

According to my former program, the requirement for low acuity setting would not be met by time at the low resource site. The low acuity site would have to be at an urgent care. Who is going to supervise residents at an urgent care given that the vast majority are staffed by midlevels???

 

[RustedFox]

If we're seriously doing rotations at urgent cares, it's so over.

 

[xaelia]

"Low acuity site" – seriously, does anyone not have enough "low acuity" in their ED?

Just let the residents work fast track for a month – tho that might count as cruel and unusual.

 

[southerndoc]

According to my former program, the requirement for low acuity setting would no be met by time at the low resource site. The low acuity site would have to be at an urgent care. Who is going to supervise residents at an urgent care given that the vast majority are staffed by midlevels???

Don't forget the burned out ER docs that work urgent cares.

 

[EctopicFetus]

Don't forget the burned out ER docs that work urgent cares.

Not many of these around here. im not sure seeing 4pph of entitled demanding people is the cure for burnout. Give me the homeless crackhead.. much easier to meet their expectations of a turkey sandwich and a place to sleep for a few hours than someone demanding an MRI, Lyme screen, and talking to their cousin who is a random specialty in another country or state who is on the phone to help manage their problem that's been ongoing for 6 months. Or the rich bank executive who wants me to call plastics for a 1 cm chin lac on their 2 year old and then gets mad when it takes too long..

 

[ERMudPhud]

Not many of these around here. im not sure seeing 4pph of entitled demanding people is the cure for burnout. Give me the homeless crackhead.. much easier to meet their expectations of a turkey sandwich and a place to sleep for a few hours than someone demanding an MRI, Lyme screen, and talking to their cousin who is a random specialty in another country or state who is on the phone to help manage their problem that's been ongoing for 6 months. Or the rich bank executive who wants me to call plastics for a 1 cm chin lac on their 2 year old and then gets mad when it takes too long..

Those were the people who showed me I couldn't work in a FSED/Urgency Center. For the few real emergencies we didn't have the resources to actually take care of them. Everyone else made me want to put an ice pick in my ear.

 

[TooMuchResearch]

"Low acuity site" – seriously, does anyone not have enough "low acuity" in their ED?

Just let the residents work fast track for a month – tho that might count as cruel and unusual.

We did two community months at a selection of sites of our choosing.

One was at a lower resource affiliate site. I did the other one at a different local level 1 trauma center.

 

[Old_Mil]

I can't help but feel that an additional year of residency would have done very little if anything for me, so I see "4 years" and think: "Laaame", but whatever.

If that's the price to pay to get rid of profligate CMG residency expansion, then good.

Since profligate CMG residency expansion is driven by the desire to staff departments with doctors working for less than PAs, I doubt that an extra year of keeping that cheap labor around will deter them. The volume requirement might have a positive effect.

 

[CliveStaples]

Since profligate CMG residency expansion is driven by the desire to staff departments with doctors working for less than PAs, I doubt that an extra year of keeping that cheap labor around will deter them. The volume requirement might have a positive effect.

I think some of the devil is in the details for the changes, aside from the 4 year program.

As an example, I believe PICU experiences are now mandated; no longer will programs be allowed to substitute NICU time for PICU time. A lot of programs opened by CMGs are lower acuity community hospitals don't have access to a PICU. I believe there are more examples of how they're "raising the standard" for programs than this.

 

[Old_Mil]

I think some of the devil is in the details for the changes, aside from the 4 year program.

As an example, I believe PICU experiences are now mandated; no longer will programs be allowed to substitute NICU time for PICU time. A lot of programs opened by CMGs are lower acuity community hospitals don't have access to a PICU. I believe there are more examples of how they're "raising the standard" for programs than this.

MICU and PICU were my two best rotations in residency (and seriously made me reconsider my life choices at the time). Hard to believe there were programs doing that.