Minimum volume for a residency program

[QuackaDO]

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So what do you think the minimum annual volume of an ED needs to be in order to provide a fair number of patients for you during training? I know it obviously depends on the number of residents so lets say with the normal startup of 8 residents, what does the census of the ED need to be able to comfortably say "you will see plenty of patients"? I don't know the "minimum" the RRC allows but I feel like it might be like 30k?

 

[Deebo84]

I believe for accreditation it has to be at least 35k but it can be a combined total from multiple ED sites which I have seen in smaller newer programs that train at multiple sites to meet or exceed that number

 

[ORL10]

I have seen lots of EM residents from diffrent programs the past year. Some from "awesome programs" some from no name programs with lower volume but who were much more skilled. The sole predictor of being a badass in my opinion is the individual willing to dedicate mass quantities of time and working really hard to be excellent, and less related to the program you go to. The programs that tend to have good names tend to get the higher quality residents and thus people think they got better training. My advice is pick a place you'll be happy, bust your a-- and you'll be fine coming out.

 

[QuackaDO]

I have seen lots of EM residents from diffrent programs the past year. Some from "awesome programs" some from no name programs with lower volume but who were much more skilled. The sole predictor of being a badass in my opinion is the individual willing to dedicate mass quantities of time and working really hard to be excellent, and less related to the program you go to. The programs that tend to have good names tend to get the higher quality residents and thus people think they got better training. My advice is pick a place you'll be happy, bust your a-- and you'll be fine coming out.

My question isn't about choosing a name or about choosing quality... it's simply asking what do people think is the minimum annual census necessary to start a program that will allow the residents to see an "adequate" number of patients. I hear on all my interviews "yeah, we see plenty of patients" but nobody every quantifies this and I wonder if some of the very low pt census numbers will deliver that so I'm hoping that someone who went to one with low numbers or knows first hand can provide some insight.

 

[RustedFox]

Yeah; - please don't take this the wrong way but - "it doesn't really matter" is the best answer. Especially given the fact that one program can/will have multiple sites, etc - and the variability in number of residents/year.

Back when I trained, if you looked at our mothership's website, you'd say - "Gee, 34,000 visits/year isn't a lot for a tertiary academic center." It didn't take into account the 48,000 visit/yr "Community General" site, and the 80-something thousand visit/year "downtown Trauma site".

 

[ORL10]

My question isn't about choosing a name or about choosing quality... it's simply asking what do people think is the minimum annual census necessary to start a program that will allow the residents to see an "adequate" number of patients. I hear on all my interviews "yeah, we see plenty of patients" but nobody every quantifies this and I wonder if some of the very low pt census numbers will deliver that so I'm hoping that someone who went to one with low numbers or knows first hand can provide some insight.

I didn't go to a program with "low numbers", but I have the distinct feeling that maybe you are asking the wrong question.

 

[deleted547339]

I didn't go to a program with "low numbers", but I have the distinct feeling that maybe you are asking the wrong question.

Would a more appropriate question be: how many pph are your interns, 2nd year and 3rd years seeing on an average shift?

 

[Arcan57]

My question isn't about choosing a name or about choosing quality... it's simply asking what do people think is the minimum annual census necessary to start a program that will allow the residents to see an "adequate" number of patients. I hear on all my interviews "yeah, we see plenty of patients" but nobody every quantifies this and I wonder if some of the very low pt census numbers will deliver that so I'm hoping that someone who went to one with low numbers or knows first hand can provide some insight.

These are all ball-park approximations:

A 3rd year resident should see 2 pts/hr. In fact, let's make that 2pph for 1st and 2nd years also. Assume that you have a minimum of one of each year in the department at a time, you're looking at needing 3x2x24 = 144 pts per day to get everyone their patients. 144 pts/day x 365 days per year gives you 52,560 visits per year (of course this can be spread out over multiple shops). Of course, what you really want to know is if small volume shops see enough acuity for you to be down with the sickness when you graduate. So what you're actually going to want is admit rates, peds volume/admit rates, and to a lesser extent data on trauma, ob/gyn, and ortho visits.

 

[QuackaDO]

Would a more appropriate question be: how many pph are your interns, 2nd year and 3rd years seeing on an average shift?

I agree, those would be good questions to ask but if it's a new residency with no residents (kinda giving it away now, lol) then that's a question that can't be answered.

These are all ball-park approximations:

A 3rd year resident should see 2 pts/hr. In fact, let's make that 2pph for 1st and 2nd years also. Assume that you have a minimum of one of each year in the department at a time, you're looking at needing 3x2x24 = 144 pts per day to get everyone their patients. 144 pts/day x 365 days per year gives you 52,560 visits per year (of course this can be spread out over multiple shops). Of course, what you really want to know is if small volume shops see enough acuity for you to be down with the sickness when you graduate. So what you're actually going to want is admit rates, peds volume/admit rates, and to a lesser extent data on trauma, ob/gyn, and ortho visits.

I agree with all of those and yeah, the numbers seem to be "ok" when added up that it "should" work out to about 1.5-2 pph but that's factoring a lot of unknowns in as knowns such as how many residents on at one time and things like that. On the good side, the number of admits I was told was around 32-33% with about 17% being ICU admits so sounds it like a pretty decent level of acuity.

Yeah; - please don't take this the wrong way but - "it doesn't really matter" is the best answer. Especially given the fact that one program can/will have multiple sites, etc - and the variability in number of residents/year.

Back when I trained, if you looked at our mothership's website, you'd say - "Gee, 34,000 visits/year isn't a lot for a tertiary academic center." It didn't take into account the 48,000 visit/yr "Community General" site, and the 80-something thousand visit/year "downtown Trauma site".

My gut tells me that you are right on this simply because they would have not received accreditation if the volume wasn't sufficient. This particular one doens't have satellite sites other than the Peds ED which is around 16K as I remember it but that could change later on if they add additional sites.

I guess I just wanted to make sure that someone on here wasn't going to fire back with a "well, I've been in a program with numbers that low and you're not going to see the patients you need to see" type of response. Seems like most, if not all, of the replies have been "It doesn't matter" which is really what I thought but wanted to see if there were any glaring oppositional feelings out there.

 

[spelledout]

i'll second the importance of acuity - a lot of programs will mention admission percentages and i think that's a better way to see what's going on and what people are learning. find out from residents how many resuscitations they do on an average shift or in a week (probably a good question for 2nd/3rd year). and resuscitation doesn't have to be trauma, ask about medical too.

 

[deleted547339]

i'll second the importance of acuity - a lot of programs will mention admission percentages and i think that's a better way to see what's going on and what people are learning. find out from residents how many resuscitations they do on an average shift or in a week (probably a good question for 2nd/3rd year). and resuscitation doesn't have to be trauma, ask about medical too.

Honestly, I care more about medical resus than trauma so I went to a program that is heavier on medical than trauma (still get plenty).

Admission rates can be a good surrogate, but I know we admit some crap for social issues.

 

[gman33]

Not sure any of these numbers really tell you that much.
Maybe some programs have too few patients. I'm not aware of any of these.
Too few patients and you might not see enough good cases.
Too many patients relative to resources, the focus will be getting the patients out of the department as soon as possible.
Not a good thing if you want to learn resus.

 

[ORL10]

I think when picking your program its more complex than "seeing medical resuscitations" or "trauma resuscitations". Are you at a program where the culture is consultants are in the ED before labs are back? DO you call cardiology when there is an arrythmia and they dictate what you do? If there is a hip dislocation is ortho contacted and they are in the ED in minutes for reduction (sure you do the sedation and maybe they "let" you do the reduction). I ask these questions because these things are not advertised, everyone tells you they run the show in the ED, until you become a consultant and see how different it is at different programs. I did residency at one site, am a fellow at another and I rotate at several sites and moonlight at a few others most with residents. Sometimes I get consulted for elevated blood glucose before the AG is back (critically high dexi = phone call to ICU fellow), others the ED has diagnosed DKA closed the gap and basically said I did your job is it cool if I send this patient to the floor?

So since its near impossible to know all the nuances of a program, I stick with pick a program you'll be happy at, be involved, read a lot and ask a lot of questions. It's ok to look dumb when you are a resident, but suddenly its embarrassing when you are an attending.