Are all programs really created equal?

[Doc Brown]

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So when I was applying for residency in Emergency Medicine this past year I kept on hearing that the RRC tightly regulates programs so that it is really hard to find a bad program.
But if you look at the checklist the RRC uses, RRC Checklist, it is not all that specific. Aside from mandating 5 hours of class/week teaching the Core Content Curriculum and the procedures list- Procedures List- there is room for so much variation that it seems to me that you can have programs that prepare you considerly better for emergency practice than others.

For example, they only mandate that 3% of your patients be ICU bound and that there be a minimum of 2 months of ICU in the residency. It would seem that a graduate of a program where 12% of patients are ICU bound that has 5 months of ICU would be better prepared to manage critically ill patients.

Even the procedure list seems a little sparse on some things. For example it seems that in a 3-4 year residency, if you are required to do only 10 reduction dislocations, someone who trained at a program where there was no orthopedics residency or they reduced 50 dislocations would be much more comfortable doing the procedures.

This doesn't even to take into account the culture of a program. Of the two programs that I rotated at, one program seemed to consult anything and everything, where the other program seemed to be much more independent and aggressively worked up patients.

Maybe I'm not saying anything new. I just kept on hearing how the RRC makes all programs superb and I guess I'm a little skeptical.

 

[docB]

I don't know that anyone has said that the RRC makes all programs "supurb." The RRC's mandate is to make sure that graduates from all programs are competent. It's also not true that all programs are equal but that doesn't make one better than another for every resident, every goal and every personality.

I have always thought that people are probably better off training in the environment in which they want to work long term. If you want to work inner city, train inner city. Same for rural. That’s definitely a guideline though. I’ve seen residents from the sticks tear up the ghetto and vice versa.

As for culture, that’s definitely not something for the RRC to regulate. Different institutions have evolved differently and that tends to determine the culture (that holds for the places you’ll work after residency too).

It’s your job to figure out which culture and residency environment is right for you. That’s why we always talk about “fit” so much. The RRC will make sure that when you graduate you can do the job. It up to you to find the place that makes you excel.

 

[BKN]

Maybe I'm not saying anything new. I just kept on hearing how the RRC makes all programs superb and I guess I'm a little skeptical.

Right. You've only got 3 or 4 years to learn 1/2 of every other specialty. No one does. Karl Mangold said that it takes 30K patients to make a good EP and 60K to make an outstanding one. It'll take you >10 years to have seen one of almost everything. And that's the good news, every days an adventure.

Because of the time constraints and the huge amount of material to be mastered, programs do vary in the experiences that they can offer to you.

Go to a tertiary center and you'll see weird stuff. But there's a price, usually less autonomy, more fellows wandering around, sticking their noses in. Possibly you'll get fewer procedures.

Go to a county and work your . . .off. Get more clinical experience, but less time with the books.

Go to a place with a lot of CCU rotations; you'll get more procedures, more resuscitations, and more experience with the very ill. But you may not be great at bread and butter outpatient EM, which still makes up the majority of patients seen in American EDs.

Go to a community hospital and learn the bread and butter, but maybe not so good at the critical care.

Pick your poison.

But, I sit on internal review committees for the other residencies on campus. I read their specialty requirements and the letters from their RRCs. By comparison our RRC is very directive, our requirements are very proscriptive and review is very complete. This has the effect of making our programs more alike than dissimilar. It also makes them very good.

BTW the checklist looks vague but it's not. Each of those questions has a great deal of subtext both from the specialty requirements and their interpretation (the unwritten rules). You can learn the unwritten part by attending briefings at CORD, SAEM, ACEP or AAEM. Or if you don't attend, you'll learn by the hard way.🙄