Big program vs. smaller ones?

[discharged]

---

Members do not see this ad.

I've heard mixed reviews from various residents I've been with. Okay, you got me- more like 2 residents. Both had different opinions:

1. bigger program so you can be confident when you graduate and be able to bang out patients just like that

2. smaller program because you get to do procedures yourself rather than consulting as you would in a larger program

What are your thoughts?

 

[turkeyjerky]

Maybe you should clarify what you mean by "bigger" and "smaller". Are you referring to patient volume, residency class size, big name academic institution (eg Duke) or highly regarded EM program (eg Cincy)?

 

[discharged]

By big, the residents were referring to the number of ER visits

 

[EM_Rebuilder]

There has to be a certain number of diversity inorder to get RRC accreditation. Outside of that, you can only see patients one at a time...

I do not think there are any programs at shops that see much less than 30K a year. I would bet that most academic places have an average in the 60-100K range. I have heard of places seeing twice that as well. Anything much over 50K and have a trauma designation and tertiary referral center is going to get you PLENTY of experience. Even without a trauma designation (which you would then probably be farmed out for the trauma experiences) you will be ok. Tertiary care/transfers are often a pain and not always the best learning experience in my opinion...

 

[deleted109597]

There are at least a few places where the residents primary hospital is a place of nearly 40K or so.
They still have trauma designations, but they don't have the sheer fire hose of patients pouring on you.
I would argue you need to be able to do your own procedures, but AFAIK there aren't any places where you consult out for everything. The only things I asked someone else to do was IR to LP someone that I couldn't get after a few tries. Otherwise, if I could do it, I did it.

As has been stated to death though, go where you want to go. Seriously.

 

[Hercules]

I think there are advantages to both. However you personally will only be able to see x patients per hour that you work which always seemed to be a point lost on most applicants. As far as impact on your learning, what's the difference between an ED that sees 100,000 and 1,000,000. I don't think those extra 900,000 patients would add much since you wouldn't see them. Just my opinion.

 

[The Buff]

I think there are advantages to both. However you personally will only be able to see x patients per hour that you work which always seemed to be a point lost on most applicants. As far as impact on your learning, what's the difference between an ED that sees 100,000 and 1,000,000. I don't think those extra 900,000 patients would add much since you wouldn't see them. Just my opinion.

I totally agree with this and do think it is lost on many applicants. I never understood why people are focused on straight voulme in EDs. It is all about the ratio of patients per resident. It is much more informative to know how many pts per shift or hour a resident is seeing vs just sheer volume. If you are the only resident at a hospital that has 40,000 visits per year, you are probably going to be ok. Likewise if that hospital has 20 residents on per shift, you might not be ok. You yourself can only see so many patients per day.

 

[deleted109597]

If you are the only resident at a hospital that has 40,000 visits per year, you are probably going to be ok.

Except that the volume of 40K is more than 100 patients per day, or more than 4 per hour. If you're the only resident, you're getting housed.

 

[gman33]

Generally I agree that pure volume isn't as important as some think.
I rotated at a student at a few places.
One saw 110k, another saw 40k.
The residents were just as busy, if not more so, at the 40k shop.
There were just less residents, attendings, mid-levels etc.

The one difference I saw is that they busier place had more mid-level support.
The residents ended up seeing a higher percentage of "sick" patients.

 

[tegs15]

It is all relative. Our hospital is a Level 1 trauma facility that is the Tertiary care center for half of the state. We are also the Stroke Center. We take Trauma and Stroke pts from a four state region. As a second/third year senior resident it is normal to see 22-25 pts per 10hr shift, and not uncommon to see > 30. Our patient population is very sick, we admit 29-31% most months. Our ED sees 47K per year, but we have a smaller community hospital in town that siphons the easy bread&butter stuff. That combined with 3 Urgent Cares (2 of which are hospital owned) and our own Fast Track, leaves us seeing PLENTY of very sick patients!

The number of ED visits alone can be very deceptive. A resident can only see so many patients, if your busy it really doesn't matter to much how many the ED as a whole sees.

 

[H2DO]

There are some programs that will have a big main hospital that you are at and then you spend a few months at a smaller community hospital, in my opinion those were the best because you get to see everthing. The more acute care and having access to specialty medicine at the tertiary centers and then having to do everything on your own at the smaller programs.

 

[Apollyon]

I understand clearly about the number of pt's a resident can see, but the bigger thing about 100k or 150k is that, simply statistically, you'll see more exotic stuff or higher absolute numbers of the sick patients. The good is better when there is a larger pool from which to choose.

Does that make sense?

 

[deleted109597]

I understand clearly about the number of pt's a resident can see, but the bigger thing about 100k or 150k is that, simply statistically, you'll see more exotic stuff or higher absolute numbers of the sick patients. The good is better when there is a larger pool from which to choose.

Does that make sense?

No doubt. For the person that sees them. The rare ones will still get seen by only one person, who may tell people about it.
Really rare stuff usually goes to a referral center, and if your ED happens to be that, you'll be aware of their presence in the ED by the number of fellows crowding around the bed not letting you near it.

However, large volume EDs don't necessarily have lots of residencies. The place I did surgery was a level 1 trauma in South Carolina, and the only residencies they had were surgery, FM, and transitional year. The ED saw more than 100K.
MUSC has a million residencies. Their ED sees less than 50K.

I think having those other specialties for advice is good. I think them running the show is bad.

 

[Apollyon]

No doubt. For the person that sees them. The rare ones will still get seen by only one person, who may tell people about it.
Really rare stuff usually goes to a referral center, and if your ED happens to be that, you'll be aware of their presence in the ED by the number of fellows crowding around the bed not letting you near it.

However, large volume EDs don't necessarily have lots of residencies. The place I did surgery was a level 1 trauma in South Carolina, and the only residencies they had were surgery, FM, and transitional year. The ED saw more than 100K.
MUSC has a million residencies. Their ED sees less than 50K.

I think having those other specialties for advice is good. I think them running the show is bad.

Yes, for the bolded, but the commonplace sick as hell patients are what train you, and, if you're seeing mostly that, vs not, then you get forged much more strongly.

And recall that I know where you did your surgery!

 

[discharged]

I agree that you can only see one patient at a time. Maybe your pacing in a small volume hospital would not be nearly sufficient for a larger one? It's much more hectic working in an ED with 15-20 charts waiting at all times vs. one that has only 5 at at time with some down time in between.

I'm only a 3rd year student and am humbly admitting that my insight is very limited.. But, the hospital I rotated at had 70k ER visits/yr. There was PLENTY of down time (a med student, 2 residents, and 2 attendings on each shift with overlap).. I couldn't imagine a place like, say.. St. Barnabas being that way?..

While high volume may be viewed as a disadvantage to many (due to the so called push to move patients out rather than actual learning, etc), I think it might help to be forced to work at a faster pace and hectic environment? In a perfect world, every EM graduate should feel confident and ready to run his own dept no matter where he trained. In reality, some residents just don't feel like they've been trained to be efficient enough..

 

[discharged]

Also, statistically speaking- you have a greater chance of seeing more of a variety in pathology in a larger volume dept. vs a smaller one.. sure, you have to play the odds. But, at least you have a higher chance?

 

[Hamhock]

As a second/third year senior resident it is normal to see 22-25 pts per 10hr shift, and not uncommon to see > 30. .

This is not good. There is NO way a second year resident should be seeing more than 3pts/hr...there is no learning there at all and patient care suffers.

And I am one who believes the pressure to see more with a rack of >20 waiting at all times is best.

------

The best, IMO, is a place that sees way more than the number of residents can handle...the "excess" is defined by the low-acuity, which is seen by mid-levels...this provides lots of sick patients for the residents.

I am concerned about places that see 30-40K....there can't be enough sick patients even if there is only three residents in each residency class.

HH

 

[SpunkyDucky]

I have been involved in both small and large residencies. Total volume is not a predictive factor of experience at all in my experience. Consider the patient population, admission percentage (higher is usually better for acuity), number of patients seen per hour, support for service, financial stability and trauma/stroke certification status. A small hospital that is a level 1, stroke center with a high admission rate would give you a great experience. So would a big hospital with the same criteria. Exotic is a not all that rare in our specialty! You will see very cool stuff everywhere.