As an EM applicant how should I be interpreting ED volume of residency programs?

[Dr.Bruh]

Just browsing the EMRA Match map and looking at random programs and notice big discrepancy of volumes in some of the programs. I really have no idea if it significant in a good or bad way. Just curious how I should interpret this when comparing programs..

For instance University of Utah (only EM program in the state) has an ED volume of 47k, while AdventHealth Orlando (one of 3 EM programs in Orlando alone) has an ED volume of 120K. Does this have any correlation to number of procedures etc? thanks!!

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[gamerEMdoc]

First, make sure that its actually the volume. Some places publish volumes of all the places residents rotate at combined. This is ok, if residents are truly staffing all those places. But if 90% of shifts are at one location, counting all the volume of a 2nd location is not really an accurate reflection of the volume the residents are exposed to.

Otherwise, consider residency size. A residency that sees 120k and has 16 residents per class and a residency that sees 60k with 8 residents per class ultimately have residents seeing about the same number of patients. The place with more patients may have the opportunity to see more rare things just strictly by numbers, but overall, you learn by what you see and seeing patients.

Divide volume by # of total EM residents in the program. Should be at least about 2000 or so patients per year per total resident in the program I'd imagine.

I am not aware of any specific volume per residency size suggestions openly published by the ACGME. I've looked extensively. I have no clue how the ACGME decides on the total number of residents they accredit a program for. I base that 2000 number only as a rough rule of thumb based on personal experience.

 

[Dr.Bruh]

First, make sure that its actually the volume. Some places publish volumes of all the places residents rotate at combined. This is ok, if residents are truly staffing all those places. But if 90% of shifts are at one location, counting all the volume of a 2nd location is not really an accurate reflection of the volume the residents are exposed to.

Otherwise, consider residency size. A residency that sees 120k and has 16 residents per class and a residency that sees 60k with 8 residents per class ultimately have residents seeing about the same number of patients. The place with more patients may have the opportunity to see more rare things just strictly by numbers, but overall, you learn by what you see and seeing patients.

Divide volume by # of total EM residents in the program. Should be at least about 2000 or so patients per year per total resident in the program I'd imagine.

I am not aware of any specific volume per residency size suggestions openly published by the ACGME. I've looked extensively. I have no clue how the ACGME decides on the total number of residents they accredit a program for. I base that 2000 number only as a rough rule of thumb based on personal experience.

Thanks this is really helpful! I got those number from the EMRA website so idk how to tell how accurate they are.

 

[Tenk]

First, make sure that its actually the volume. Some places publish volumes of all the places residents rotate at combined. This is ok, if residents are truly staffing all those places. But if 90% of shifts are at one location, counting all the volume of a 2nd location is not really an accurate reflection of the volume the residents are exposed to.

Otherwise, consider residency size. A residency that sees 120k and has 16 residents per class and a residency that sees 60k with 8 residents per class ultimately have residents seeing about the same number of patients. The place with more patients may have the opportunity to see more rare things just strictly by numbers, but overall, you learn by what you see and seeing patients.

Divide volume by # of total EM residents in the program. Should be at least about 2000 or so patients per year per total resident in the program I'd imagine.

I am not aware of any specific volume per residency size suggestions openly published by the ACGME. I've looked extensively. I have no clue how the ACGME decides on the total number of residents they accredit a program for. I base that 2000 number only as a rough rule of thumb based on personal experience.

Very good info, just wanted to add: ask how many outside learners rotate in your ED. We had three sites and our busiest (~100,000) had ONLY our ed program. The trauma service was also run by PAs who were chill and let you have all the procedures if you just asked. I learned the most at this site as opposed to our academic site which was overflowing with off service residents of every specialty. Even if you have a strong ED, competing with no one is a lot easier than competing with other residents.

 

[gamerEMdoc]

Idk, nothing against off service residents, but we usually have 1-2 on a day and if they see 5 patients a day a piece, I'd be surprised. Unless the department is absolutely overflowing with off service rotators, I doubt they are clipping off much volume.

 

[Rekt]

I agree with Tenk depending on the place. I'd personally ask about non-physician provider roles in the ED. If you're competing with them for procedures, etc. Especially if there's a pseudo-mid-level "residency" there (I wouldn't even rank them, but anyway).

 

[PianoMedic]

First, make sure that its actually the volume. Some places publish volumes of all the places residents rotate at combined. This is ok, if residents are truly staffing all those places. But if 90% of shifts are at one location, counting all the volume of a 2nd location is not really an accurate reflection of the volume the residents are exposed to.

Otherwise, consider residency size. A residency that sees 120k and has 16 residents per class and a residency that sees 60k with 8 residents per class ultimately have residents seeing about the same number of patients. The place with more patients may have the opportunity to see more rare things just strictly by numbers, but overall, you learn by what you see and seeing patients.

Divide volume by # of total EM residents in the program. Should be at least about 2000 or so patients per year per total resident in the program I'd imagine.

I am not aware of any specific volume per residency size suggestions openly published by the ACGME. I've looked extensively. I have no clue how the ACGME decides on the total number of residents they accredit a program for. I base that 2000 number only as a rough rule of thumb based on personal experience.

2000 seems close to what acgme would require per resident I think: minimum of 6 residents per class and it used to be minimum of 35,000 per year visit volume through the ED. That would be about 1950 patients per resident on average. Also don't know where there numbers come from, but those used to be the minimums.

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[MedicineZ0Z]

Idk, nothing against off service residents, but we usually have 1-2 on a day and if they see 5 patients a day a piece, I'd be surprised. Unless the department is absolutely overflowing with off service rotators, I doubt they are clipping off much volume.

What do you expect from your interns and seniors? I was seeing 12-15 per shift as an off-service, included a couple ICU bound patients at least too. Pretty much no level 4s.
No one talked to me about appropriate and high volume per resident and I paid minimal attention to other residents. Got an extremely positive eval with minimal actual feedback/writing.

 

[gutonc]

Idk, nothing against off service residents, but we usually have 1-2 on a day and if they see 5 patients a day a piece, I'd be surprised. Unless the department is absolutely overflowing with off service rotators, I doubt they are clipping off much volume.

As a former off service rotating resident, I will say that 5 a shift (assuming 10-12 hours/shift) is generous.

What do you expect from your interns and seniors? I was seeing 12-15 per shift as an off-service, included a couple ICU bound patients at least too. Pretty much no level 4s.
No one talked to me about appropriate and high volume per resident and I paid minimal attention to other residents. Got an extremely positive eval with minimal actual feedback/writing.

ROFLWUT?

 

[Apollyon]

Duke IM residents struggled to see 0.5/hr, and were legitimately quizzical when told that they couldn't sign out a pelvic exam.

At the same time, there are always outliers. There was one IM res that really got into it, and even got in the traumas (and surgery welcomed her, when they saw her to be eager and able). She's heme/onc now.

 

[gamerEMdoc]

Yeah we have had outliers in the past who could basically hang in the ED at a junior resident level, but that is a vast minority of off service rotators.

 

[TheSingularity]

We had an IM rotator essentially enter a catatonic state after the presentation of the 3rd or 4th critically ill patient to the pod.

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[deleted109597]

Try peds residents.
"We can only see kids. And no procedures. And we leave every day at noon for conference. kthxbye"

 

[MedicineZ0Z]

As a former off service rotating resident, I will say that 5 a shift (assuming 10-12 hours/shift) is generous.


ROFLWUT?

????

 

[NurWollen]

Try peds residents.
"We can only see kids. And no procedures. And we leave every day at noon for conference. kthxbye"

You mean they actually tell you they don't want procedures? Are you sure you're not just assuming that? Because as a peds resident I have to beg ED attendings to let me do the procedures and not just just hand those patients to the EM resident. I don't see adults though, because that's not what I do. I see as many kids in a shift as the EM residents do on their peds shifts.

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[deleted109597]

You mean they actually tell you they don't want procedures? Are you sure you're not just assuming that? Because as a peds resident I have to beg ED attendings to let me do the procedures and not just just hand those patients to the EM resident. I don't see adults though, because that's not what I do. I see as many kids in a shift as the EM residents do on their peds shifts.

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Yeah. I've had them tell me "no thanks" to procedures. And this was at a peds hospital, with peds residents. Some just don't want to do them. The only ones who did were the ones going into PEM, and, uh, yeah that's it. Everyone else was like "I won't have to do this ever again, might as well start now."
But hey, I'm glad you are working hard. Keep at it.

 

[MedicineZ0Z]

Yeah. I've had them tell me "no thanks" to procedures. And this was at a peds hospital, with peds residents. Some just don't want to do them. The only ones who did were the ones going into PEM, and, uh, yeah that's it. Everyone else was like "I won't have to do this ever again, might as well start now."
But hey, I'm glad you are working hard. Keep at it.

Is that really a bad thing? The ones who should get practice are the ones who will do it post residency.

 

[deleted109597]

Is that really a bad thing? The ones who should get practice are the ones who will do it post residency.

Not entirely inaccurate. However, most of the scut we get tasked with on offservice rotations we will never do. And it isn't educational either. So either they treat us like we allow them, or they can suck it up.
Besides, I'm not asking them to put in chest tubes and intubate. I'm asking them to do minor suturing, pediatric LPs, things like that.

 

[psychapp121]

What do you expect from your interns and seniors? I was seeing 12-15 per shift as an off-service, included a couple ICU bound patients at least too. Pretty much no level 4s.
No one talked to me about appropriate and high volume per resident and I paid minimal attention to other residents. Got an extremely positive eval with minimal actual feedback/writing.

wtf why

 

[MedicineZ0Z]

Not entirely inaccurate. However, most of the scut we get tasked with on offservice rotations we will never do. And it isn't educational either. So either they treat us like we allow them, or they can suck it up.
Besides, I'm not asking them to put in chest tubes and intubate. I'm asking them to do minor suturing, pediatric LPs, things like that.

When I was offservice on EM, the other offservice residents would give me their procedures because I'll be practicing in an open ICU setting and doing rural practice post residency. Those other residents won't ever do an LP but I will after residency. Even the EM seniors seemed cool with handing some stuff away cause they had done so many.

 

[MedicineZ0Z]

wtf why

Why what? You see a patient, put in orders as you're seeing them and start up the HPI on the note.
Either see my staff or see another one if they're busy. That's how you can see so many and keep the ER flowing efficiently rather than sit on a patient for an hour making 0 progress like this thread suggests.

This may not work at other ERs if culturally residents are expected to present patients before putting in orders. To be fair, they generally expect non-FM/IM off service people to do that here as well.

 

[Rekt]

Why what? You see a patient, put in orders as you're seeing them and start up the HPI on the note.
Either see my staff or see another one if they're busy. That's how you can see so many and keep the ER flowing efficiently rather than sit on a patient for an hour making 0 progress like this thread suggests.

This may not work at other ERs if culturally residents are expected to present patients before putting in orders. To be fair, they generally expect non-FM/IM off service people to do that here as well.

I like you, but no man, you aren't seeing 15/shift as an off service unless your shop is really low acuity.

 

[MedicineZ0Z]

I like you, but no man, you aren't seeing 15/shift as an off service unless your shop is really low acuity.

I said 12-15. It's a level 1 trauma.

 

[DrDrummer]

I like you, but no man, you aren't seeing 15/shift as an off service unless your shop is really low acuity.

Remember that different places have different shift lengths. This is a more impressive number during an 8 hour shift than during a 12 hour shift.

 

[MedicineZ0Z]

Remember that different places have different shift lengths. This is a more impressive number during an 8 hour shift than during a 12 hour shift.

9 hour shifts.

 

[mega_colon]

5 is amazing for an off service, with 3-4 per 8 hour shift being the norm. Even in the peds ED when working with a senior peds resident they will only see 5-8 in a shift and those kids are pretty easy to see quickly.

 

[MedicineZ0Z]

5 is amazing for an off service, with 3-4 per 8 hour shift being the norm. Even in the peds ED when working with a senior peds resident they will only see 5-8 in a shift and those kids are pretty easy to see quickly.

I can't wrap my head around how seeing so few patients is even possible. The history and physical should not exceed 10 minutes and I'm often putting in orders at that time. Following up on tests is done on the fly as is talking to consultants when necessary.

 

[psychapp121]

I can't wrap my head around how seeing so few patients is even possible. The history and physical should not exceed 10 minutes and I'm often putting in orders at that time. Following up on tests is done on the fly as is talking to consultants when necessary.

there are some off service that see 1 per shift with 3-4 being typical, you’re seeing 15 lol

 

[Lexdiamondz]

there are some off service that see 1 per shift with 3-4 being typical, you’re seeing 15 lol

Yeah I call BS...an off service FM intern 4 mos into residency seeing 15 pts/shift is highly unlikely

 

[VA Hopeful Dr]

Yeah I call BS...an off service FM intern 4 mos into residency seeing 15 pts/shift is highly unlikely

I'm forced to agree. An intern in April could potentially pull that off in the low acuity part of the ED, but not that early unless its the lowest acuity ED in the country (and even then I'm skeptical).

 

[MedicineZ0Z]

there are some off service that see 1 per shift with 3-4 being typical, you’re seeing 15 lol

That's mind boggling dude. I literally explained my work flow. How is a resident seeing so few?

My guess is most shops require residents, especially off service, to staff a patient prior to putting in orders. That can significantly impede workflow compared to my shop.

 

[psychapp121]

I'm forced to agree. An intern in April could potentially pull that off in the low acuity part of the ED, but not that early unless its the lowest acuity ED in the country (and even then I'm skeptical).

I thought you were FM?

 

[VA Hopeful Dr]

I thought you were FM?

I am so I have a decent idea what an FM intern is capable of (I was one 9 years ago, after all).

 

[deleted109597]

I have no doubt an FM intern "saw" 15 patients in 9 hours. As in, walked by their room or poked their head in with someone else.
I don't think they worked them up, wrote the note, and dispositioned them.


If they did, then they're a unicorn.

 

[Birdstrike]

Just browsing the EMRA Match map and looking at random programs and notice big discrepancy of volumes in some of the programs. I really have no idea if it significant in a good or bad way. Just curious how I should interpret this when comparing programs..

For instance University of Utah (only EM program in the state) has an ED volume of 47k, while AdventHealth Orlando (one of 3 EM programs in Orlando alone) has an ED volume of 120K. Does this have any correlation to number of procedures etc? thanks!!

Acuity matters. You want a place where you see a representative mix of acuity. But placing too much importance on volume, is a mistake in my opinion. Whether the ED sees 120K or 60K per year, the place is going to be staffed so each individual doctor sees approximately the same per hour. Also, you could be at a place with twice the volume and personally see less volume (and vice versa) depending on how heavily, or lightly they staff the joint. You don't need an ED to see 120,000 patients each year. Considering you won't be working in the ED every month, you won't likely even see 1% of that in a years time. In Emergency Medicine, you're not going to have a shortage of patients, my friend. That's not a thing.

 

[Apollyon]

Acuity matters. You want a place where you see a representative mix of acuity. But placing too much importance on volume, is a mistake in my opinion. Whether the ED sees 120K or 60K per year, the place is going to be staffed so each individual doctor sees approximately the same per hour.

True, but, like said above, the higher the gross number of pts seen, the more likely, statistically, to see a zebra. As a resident, then, more likely to get called over "to see this", even if not as primary.

 

[Rekt]

Acuity matters. You want a place where you see a representative mix of acuity. But placing too much importance on volume, is a mistake in my opinion. Whether the ED sees 120K or 60K per year, the place is going to be staffed so each individual doctor sees approximately the same per hour. Also, you could be at a place with twice the volume and personally see less volume (and vice versa) depending on how heavily, or lightly they staff the joint. You don't need an ED to see 120,000 patients each year. Considering you won't be working in the ED every month, you won't likely even see 1% of that in a years time. In Emergency Medicine, you're not going to have a shortage of patients, my friend. That's not a thing.

While the staffing thing is obviously true, if a place is not "resident run" then higher volume is only helpful. We see a significant majority of all the patients that roll through our shop, but we're still not completely resident run due to our sheer volume. Docs pass off real pathology and procedures to us on top of our normal patient load or will often take the psych/druggie/malingerer instead of taking the hypotensive nursing home pt.

 

[MedicineZ0Z]

I have no doubt an FM intern "saw" 15 patients in 9 hours. As in, walked by their room or poked their head in with someone else.
I don't think they worked them up, wrote the note, and dispositioned them.


If they did, then they're a unicorn.

Most of our interns it sounds like see about 6-10 per shift.

 

[NurWollen]

Yeah. I've had them tell me "no thanks" to procedures. And this was at a peds hospital, with peds residents. Some just don't want to do them. The only ones who did were the ones going into PEM, and, uh, yeah that's it. Everyone else was like "I won't have to do this ever again, might as well start now."
But hey, I'm glad you are working hard. Keep at it.

That's a shame. A bit embarrassed for my specialty to be honest. I would say that culturally, we're less likely to feel comfortable just kind of winging it than an EM resident, but there's no procedure I wouldn't want to do with an attending supervising.

5 is amazing for an off service, with 3-4 per 8 hour shift being the norm. Even in the peds ED when working with a senior peds resident they will only see 5-8 in a shift and those kids are pretty easy to see quickly.

As a senior peds resident, I usually see 10-12 in a 10 hour shift. If I see fewer than that it's because it was a slow day and the EM resident doing a peds shift would have seen fewer as well. In other words, I usually see about as many as the EM resident. Admittedly, most of that is real low acuity urgent care kind of stuff (or the kind of stuff we should be seeing continuity clinic), but occasionally we get someone who's pretty sick. I'll admit someone to the PICU from the ER every few shifts or so, and usually 1 or 2 to the floor per shift.

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[psychapp121]

That's a shame. A bit embarrassed for my specialty to be honest. I would say that culturally, we're less likely to feel comfortable just kind of winging it than an EM resident, but there's no procedure I wouldn't want to do with an attending supervising.As a senior peds resident, I usually see 10-12 in a 10 hour shift. If I see fewer than that it's because it was a slow day and the EM resident doing a peds shift would have seen fewer as well. In other words, I usually see about as many as the EM resident. Admittedly, most of that is real low acuity urgent care kind of stuff (or the kind of stuff we should be seeing continuity clinic), but occasionally we get someone who's pretty sick. I'll admit someone to the PICU from the ER every few shifts or so, and usually 1 or 2 to the floor per shift.

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how is that embarassing? You think it’s smart of you to subject the patient to a higher risk of complications when you won’teven be benefitting from the procedure since you’ll never have to do it again? The smart, compassionate resident would say “no thanks”

 

[NurWollen]

how is that embarassing? You think it’s smart of you to subject the patient to a higher risk of complications when you won’teven be benefitting from the procedure since you’ll never have to do it again? The smart, compassionate resident would say “no thanks”

Bull. I'm talking about properly supervised procedures. And who are you to say I'll never be doing them again? Maybe that resident plans on doing PEM. You don't think there are general pediatricians who need to be able to intubate a neonate? Or do an LP on a neonate? Or sedate an older kid. Or splint a fracture?

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[RustedFox]

You don't think there are general pediatricians who need to be able to intubate a neonate? Or do an LP on a neonate? Or sedate an older kid. Or splint a fracture?

No.
They send all those things to the ER.

 

[deuist]

Bull. I'm talking about properly supervised procedures. And who are you to say I'll never be doing them again? Maybe that resident plans on doing PEM. You don't think there are general pediatricians who need to be able to intubate a neonate? Or do an LP on a neonate? Or sedate an older kid. Or splint a fracture?

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No, those jobs are performed by pediatric anesthesiologists and pediatric emergency physicians. Occasionally a general pediatrician may give out an air cast in clinic for a sprain, but there's no way in hell they're using plaster in the office for a fracture.

 

[Dr Mantis Toboggan]

Plenty of community pediatricians still attend deliveries and resuscitate floppy newborns. Highly common in rural areas.

No, those jobs are performed by pediatric anesthesiologists and pediatric emergency physicians. Occasionally a general pediatrician may give out an air cast in clinic for a sprain, but there's no way in hell they're using plaster in the office for a fracture.

 

[TheSingularity]

Ha yeah sure. You have no idea.

One of the locums gen peds I've worked with in the er has been in places where she's had to intubate and drop umbi lines.

Any office based general pediatrician worth their salt should be able to repair lacerations and drain abscesses without punting to the ED.

No, those jobs are performed by pediatric anesthesiologists and pediatric emergency physicians. Occasionally a general pediatrician may give out an air cast in clinic for a sprain, but there's no way in hell they're using plaster in the office for a fracture.

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[NurWollen]

No.
They send all those things to the ER.

Sure, some do. Maybe a majority. But as others have noted, there are many, many general pediatricians who still attend deliveries. A lot of peds hospitalist jobs (ironically in the places that won't likely ever have a fellowship trained hospitalist) really want people who are comfortable attending deliveries. I know of general pediatricians who intubate prematire babies in the delivery room and place umbilical lines before shipping them to the nearest NICU. We're not even talking that rural. Cities of 50k in middle America.

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[psychapp121]

Sure, some do. Maybe a majority. But as others have noted, there are many, many general pediatricians who still attend deliveries. A lot of peds hospitalist jobs (ironically in the places that won't likely ever have a fellowship trained hospitalist) really want people who are comfortable attending deliveries. I know of general pediatricians who intubate prematire babies in the delivery room and place umbilical lines before shipping them to the nearest NICU. We're not even talking that rural. Cities of 50k in middle America.

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Regardless, if you’re among the majority of pediatricians not going to be utilizing those skills, it’s not “embarassing” as you put it to decline a procedure which saves the patient both risk of complication as well as allows someone more likely to utilize that skill set in the future to hone their skills

 

[MedicineZ0Z]

Regardless, if you’re among the majority of pediatricians not going to be utilizing those skills, it’s not “embarassing” as you put it to decline a procedure which saves the patient both risk of complication as well as allows someone more likely to utilize that skill set in the future to hone their skills

Yes on the second part but not sure why you bring up the risk of complication as if inexperienced supervised learners constantly lead to harm. Inexperience often comes with caution and doing a procedure safely is quite easy when supervised. Does it mean you'll get it? No. But also means you won't cause harm.

 

[psychapp121]

Yes on the second part but not sure why you bring up the risk of complication as if inexperienced supervised learners constantly lead to harm. Inexperience often comes with caution and doing a procedure safely is quite easy when supervised. Does it mean you'll get it? No. But also means you won't cause harm.

Inexperienced people have higher complication rates..

 

[MedicineZ0Z]

Inexperienced people have higher complication rates..

Source on inexp people who are supervised having higher complication rates?