Community Practice

[Okieboy]

---

Members don't see this ad.

Hello,

4th year student here. I read with interest CorpsmanUP's experience with practicing in the community as well as other posts of people describing their own experiences. I have a question that I hope some can answer. I'm trying to decide between two residencies. The first one prides itself in being able to prepare it's resident to practice in any community environment. 3rd year residents boast they can easily manage 40 patients per 12 hour shift...and this is with a fast track in place that sees the low acuity patients. I rotated there and found that they were more likely to practice defensive medicine, with nurses being able to order pre-defined tests even before the docs saw the patients.

The other residency is heavy on didactics and EBM, however, the 3rd year residents only see 2 to 2.5 patients per hour.

My goal is to practice in the community upon completion of residency, so my question is this...is the real world of community practice more like the first residency I mentioned, where you are expected to see as many patients as possible and practice more of a "CYA" type of medicine? If so, I feel this first residency would indeed better prepare me for that environment. However, I feel that I would be missing the ability to build a foundation of solid EBM.

Any insight would be appreciated.

Thanks.

 

[deleted109597]

The first one prides itself in being able to prepare it's resident to practice in any community environment. 3rd year residents boast they can easily manage 40 patients per 12 hour shift...and this is with a fast track in place that sees the low acuity patients.

That just seems like a lot. Pulling more than 3 patients per hour for 12 hours is brutal. Especially if they're all "sick". Either those residents then spend the next 4 hours dictating/writing the charts, or they don't see that many.

The other residency is heavy on didactics and EBM, however, the 3rd year residents only see 2 to 2.5 patients per hour.

Only? Just wait, big boy. I long for a day when someone says I only see 2.5 per hour

My goal is to practice in the community upon completion of residency, so my question is this...is the real world of community practice more like the first residency I mentioned, where you are expected to see as many patients as possible and practice more of a "CYA" type of medicine? If so, I feel this first residency would indeed better prepare me for that environment. However, I feel that I would be missing the ability to build a foundation of solid EBM.

Your ability to practice EBM has nothing to do with you, and everything with how the facility operates. You're not going to buck any system.

 

[Hamhock]

3rd year residents boast they can easily manage 40 patients per 12 hour shift...and this is with a fast track in place that sees the low acuity patients

I'll be a bit more candid that Ninja.

Regarding the 40 pts/12hours for residents:

bull****
...or dangerous
...but more likely bull****

I am confident (admittedly without supporting evidence or experience) in saying:

Do not train in any place that has residents seeing 40 patients in 12 hours.

HH

 

[alreadylernd]

Community practice and residency training (ie: academia) are very different - if you're entirely set on going into the community after residency, choose a program that offers more community ED months during your training or trains at multiple sites so you get a feel for how things are done in different places and in different settings. You'll find that how things are done at the big academic medical center (regardless of how many patients per-hour the residents boast about - undoubtedly to impress wide-eyed medical students) are not how things are done in community hospitals that do not have the resources (read: residents and subspecialty support) the big house does.

 

[ihearttriangles]

I'll be a bit more candid that Ninja.

Regarding the 40 pts/12hours for residents:

bull****
...or dangerous
...but more likely bull****

I am confident (admittedly without supporting evidence or experience) in saying:

Do not train in any place that has residents seeing 40 patients in 12 hours.

HH

Regardless of the exact numerical difference between number of pts seen, I think Okie's question is a good one. Does training at an academic program adequately prepare you for community practice? It just so happens that last night I read an article in Emergency Medicine News that addresses this very issue. Hope you find it of use.

http://journals.lww.com/em-news/Ful...ng_Our_Residents__Training_ED_Docs_for.5.aspx

 

[Hamhock]

Regardless of the exact numerical difference between number of pts seen, I think Okie's question is a good one. Does training at an academic program adequately prepare you for community practice? It just so happens that last night I read an article in Emergency Medicine News that addresses this very issue. Hope you find it of use./QUOTE]

I will read the article tonight when I get home. However, I stand by my assertion: Do not train anywhere that has residents seeing 40 pts/12 hours.

OTH, I completely agree that there are programs that better prepare residents for the community and many of the "academic" programs are not included in that list.

Again: Not all programs are the same and you will NOT get the same training at every EM program...as much as we all like to pretend this is true.

HH

 

[xaelia]

It is better to train at a program that values training residents to know what they're doing, rather than pushing them to work fast without fully understanding why.

That being said, patients per hour is just one part of the equation.

As a side note, the literature from multiple institutions that have published their resident PPH numbers shows numbers between 1-1.5 patients per hour on average, increasing through residency.

 

[deleted65604]

I also call BS on seeing 40 patients in a 12 hour period, unless you are being creative with the definition of "seeing". To me, "seeing" a patient is being the first person to interview a patient and start the disposition, order labs, and treat, followed by performing all required procedures and writing up the disposition, and giving discharge advice to the patient. My impression is that at some places, attendings use 3rd or 4th year residents as an additional attending to bird dog sick patients, keep an eye on the flow of the department, recieve H and P info from medical students and junior residents, and supervise minor procedures. While beneficial to the attendings on the shift, this might not make you the best attending physician. It creates residents with over-inflated egoes who actually believe they can move 40 patients in a 12 hour shift.

The vast majority of those "40" patients that they "saw" they might have never even done a physical exam on, let alone taken a history, or done any paper-work on. If you want to go into academics, you should go to a residency that has this more supervisory role in the 3rd and 4th year, to experience the pain of listening to stupid medical students giving report and trying desparately to not allow residents to commit malpractice.

 

[Greenbbs]

the only time I've EVER seen 40 people in a shift is when i'm our Triage doc, and i'm dispo-ing ankle sprains and medication refills. I usually see 18-20 patients on a regular ED shift

 

[EctopicFetus]

I too am an attending and only with PA's do i see 4 patients per hour.

Our private group average is 1.8 per hour and I would say I see just about 2 pph. No resident can see 3 pph if there is any acuity. Think about what that means. 20 mins per patient including charting, procedures, phone calls, physical exam, ordering and reviewing labs. This is a no go for a resident who needs to also staff those patients.

 

[Okieboy]

This is a no go for a resident who needs to also staff those patients.

At this program in question, the third years do not staff their patients. Looking back however, there did seem to be a fair amount of return visits of recently discharged patients.

There was a thread last month started by a new attending physician who described a sharp learning curve moving from residency to real world. More specifically, not being able to handle the increase in the amount of patients he was expected to see. This seemed to be echoed by other new attending physicians as well.

I appreciate the thoughts of those who have posted in response.

 

[Greenbbs]

At this program in question, the third years do not staff their patients. Looking back however, there did seem to be a fair amount of return visits of recently discharged patients.

There was a thread last month started by a new attending physician who described a sharp learning curve moving from residency to real world. More specifically, not being able to handle the increase in the amount of patients he was expected to see. This seemed to be echoed by other new attending physicians as well.

I appreciate the thoughts of those who have posted in response.

I don't necessarily think there's a sharp learning curve in terms of moving the meat between being a resident and an attending (at least for me). The sharpest part of the curve is realizing that it's your ass on the line now instead of your residency attending's ass, and that's where it gets tough. you do a lot more second guessing yourself, and a lot more defensive stuff at the beginning.

 

[deleted109597]

You're going to have to name the program now.
If you're actually saying that the program violates RRC rules that's a pretty ballsy statement.

Moonlighting really lets you know if you are ready.


On the rare occasion that I see 3 pph (as a 3rd year), universally it is on the lower acuity side, and none of those patients require a lot. If they start requring pelvics, or ultrasounds, or anything that takes time, you start slowing down. If they're all simple, it can be done, but you feel tired at the end.

 

[lucky_deadman]

At this program in question, the third years do not staff their patients.

This is dangerous; medically, legally, and financially.

 

[NERDY]

What are some solid community based residency programs? Thanks.

 

[inspirationmd]

What are some solid community based residency programs? Thanks.

In Chicago I can vouch for Advocate Christ and Resurrection. The University of Illinois -Chicago is academic overall but you rotate through community hospitals of various sizes and can get a well rounded experience.

 

[RustedFox]

3rd years that dont staff their patients ?

In what GALAXY, bud ?!

 

[KarlPilkington]

I trained in a community program, at our busiest we saw ~3 an hour, and that felt out of control.
I worked for a while in the community. I would think twice before taking a job where you average over 2.5 an hour, to do that regularly you need some good ancillary services in place, you need a mix of lower acuity, and your nurses need to be on board, otherwise it will crush your soul pretty rapidly. There are community jobs out there that see twice this many per hour...most of these are not good community jobs.
I call shenanigans on the residency that has third years seeing 3-4 pts/hr. I now work in academics and on a busy shift with residents and mid-levels I rarely hit a steady 4/hour for the whole shift. Sometimes I'll see 10 in an hour and other times I'll just see 2, but its actually rare to average 4 throughout the entire shift.
As others have said, I would not go to this residency under any circumstances. It is crazy and dangerous to train somewhere that lets third years see all patients without an attending.

Here is my non-comprehensive list of "community" minded residency programs:
Carolinas, Carilion (Roanoke), Maine Med, Christiana.

 

[pinipig523]

3rd years that dont staff their patients ?

In what GALAXY, bud ?!

In my old program - even us 4th years still staffed patients unless we were in fast track.

 

[Okieboy]

3rd years that dont staff their patients ?

In what GALAXY, bud ?!

Louisville.

 

[RustedFox]

Louisville.

Well, you heard it here first.... someone oughta say something about medicare fraud at this point.

 

[Arcan57]

Well, you heard it here first.... someone oughta say something about medicare fraud at this point.

Yeah, it's not like the people responsible for training residents suddenly decided that they weren't supervising closely enough back in the 90's. Back before the change, the attendings at our program would sleep at night on shift and only be woken up if necessary to fight with consultant attendings. If they're signing charts they didn't see the patient on and those patients are Medicare, UoL is going to owe a redonkulous amount of money to the Feds.

 

[MedicalStudent5]

You're going to have to name the program now.
If you're actually saying that the program violates RRC rules that's a pretty ballsy statement.

Moonlighting really lets you know if you are ready.


On the rare occasion that I see 3 pph (as a 3rd year), universally it is on the lower acuity side, and none of those patients require a lot. If they start requring pelvics, or ultrasounds, or anything that takes time, you start slowing down. If they're all simple, it can be done, but you feel tired at the end.

Thanks for sharing your experience, it was really helpful.

 

[name?]

Hello,

4th year student here. I read with interest CorpsmanUP's experience with practicing in the community as well as other posts of people describing their own experiences. I have a question that I hope some can answer. I'm trying to decide between two residencies. The first one prides itself in being able to prepare it's resident to practice in any community environment. 3rd year residents boast they can easily manage 40 patients per 12 hour shift...and this is with a fast track in place that sees the low acuity patients. I rotated there and found that they were more likely to practice defensive medicine, with nurses being able to order pre-defined tests even before the docs saw the patients.

The other residency is heavy on didactics and EBM, however, the 3rd year residents only see 2 to 2.5 patients per hour.

My goal is to practice in the community upon completion of residency, so my question is this...is the real world of community practice more like the first residency I mentioned, where you are expected to see as many patients as possible and practice more of a "CYA" type of medicine? If so, I feel this first residency would indeed better prepare me for that environment. However, I feel that I would be missing the ability to build a foundation of solid EBM.

Any insight would be appreciated.

Thanks.

Those number(40/12hr) aren't sustainable, safe or realistic. Shoot for a solid mix of bedside teaching and EBM/academics which can be found at most residencies and don't worry about making the transition at the end. Practice pace/style and expectations vary even out in the community, so you're best served with a broad-based, solid education and worry about the finer points of community practice when you're out there. It's not a seamless transition plan, but it's what most people do.

And, just so you know, 2.5 pph when dealing with teaching junior residents, presenting your cases and running codes/traumas etc is nothing to sneeze at. I'd argue that even that number is probably a bit inflated.

My shop is currently about 1.8/hour in the community without PAs and even those days can feel busy when they're old abdominal pain/weakness/"not feeling right" kind of cases which is my community's bread and buttter.