Question for EM residents

[AVD]

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Does your program pay attention on how many patients you see per hour? Is this an emphasis in your evaluation as a EM resident?

When working in the ED, do upper-level residents throw patients at interns (regardless of their patient load at the time)?

What do you think of the volume over quality philosophy of learning?

 

[Sessamoid]

Originally posted by AVD
Does your program pay attention on how many patients you see per hour? Is this an emphasis in your evaluation as a EM resident?

When working in the ED, do upper-level residents throw patients at interns (regardless of their patient load at the time)?

What do you think of the volume over quality philosophy of learning?

Our residency kept track of those numbers only to watch out for the outliers. They tried not to have people either rushing through workups unnecessarily, nor bogging down the ER with unnecessary workups. And such information is useful for the resident to have as well. When you hit the real world, how many patients you can see has an effect on who will hire you and how much you will get paid. I think a residency program should pay attention to these numbers.

As a senior resident (and asst. chief res) I pushed those interns and second-years that I thought weren't moving at a level commensurate with their peers in their class. Those that moved at a good pace, I largely left alone. The senior residents' (the better trusted ones anyway) opinions re: the performance of the interns was always considered, though the interns at my program always presented their cases to an attending at some point. How closely the interns are monitored and pushed will vary from program to program however.

The way I figure it, an EM intern is going to be a drag on the productivity of the ER for at least the first half of the internship. The really good ones will be performance-neutral (i.e. they won't be a net drag on the ER) by midway through the intern year, though most will only reach that point at the beginning of the second year. After that they should be a net positive for the ER. Interns not only have to be watched like hawks, but they also require a lot of teaching time, so they should be a drag on the performance of the ER, because performance isn't the primary goal of a teaching program. It's expected, and a program shouldn't push the interns so hard that they are dangerous. If the volume/acuity get that bad, then the attendings really need to start seeing the excess patients to pick up the slack, and my program did just that for the most part.

I think residents should always be pushed so that they find themselves just a little uncomfortable (with the volume and/or acuity) a significant portion of the time. If they're not feeling like that, they're probably not getting enough education or just happen to be insanely competent.

 

[Apollyon]

Originally posted by Sessamoid
though the interns at my program always presented their cases to an attending at some point. How closely the interns are monitored and pushed will vary from program to program however.

The way I figure it, an EM intern is going to be a drag on the productivity of the ER for at least the first half of the internship. The really good ones will be performance-neutral (i.e. they won't be a net drag on the ER) by midway through the intern year, though most will only reach that point at the beginning of the second year.

just happen to be insanely competent.

In our program (and at others I've seen), the EM residents pick up the cases like everyone else, plus have cases assigned above and beyond (like traumas and transfers), versus in place of; that's just immersion and "trial by fire", the way I see it.

Unfortunately, the volume also is a necessary evil. At Mt. Sinai, everyone is seen as soon as possible. At Elmhurst, the volume is crushing, so, all shifts start at 7a and 7p; at 6a or 6p, you don't see any new patients, and button up what you can so that you sign out as little as possible. If you're at Sinai, and a patient is put in a bed at 6:45, you're seeing them. If there aren't enough seats to put the asses in, you can't keep your percentage up of seeing patients. I can't approach 1 patient per hour, because they just aren't here.

 

[DrQuinn]

Our PD wants us to see 1.5 pt/hr our intern year, and work up to 2.5-3 pt/hr (I think) by the time we're a senior resident...

We did an "ED Orientation month" in July... and I had a few shifts in the ED as an intern... I managed about 1 pt an hour... but usually got bottlenecked by the end of the shift with either admissions or too many critically ill patients to see any new ones... You throw a code in anywhere and my rhythm gets thrown off (unless the patient doesn't survive then it's pretty simple).

Q, DO

 

[PimplePopperMD]

AT some programs, (Ressurection in Chicago for example) a patient log is mandatory for EM residents, and they must track all patients they see (per the interview I had in 2/03). Some programs are totally hands off, and it's up to the senior residents to pick up the "slower than normal intern" intern. It's a frustrating process for all involved; as an intern, I'd LIKE to be faster, more competent, and not such a drag, but our program constantly tells us that it is not our job to "move the meat". When looking for a program, look for the program director to say something of this ilk; that the intern is not expected to be fast, and in fact, as mentioned earlier, are EXPECTED to be slow, so they can learn.

 

[AVD]

Originally posted by QuinnNSU
Our PD wants us to see 1.5 pt/hr our intern year, and work up to 2.5-3 pt/hr (I think) by the time we're a senior

Q, DO

Those numbers sound high (ouch). Anybody else's programs give real numbers? (Do most programs have specific pt./hour number expectations for each level resident?)

Mine are 1 pt./hr as an intern, and 2pts./hr as a senior. (3 yr program)

Art

 

[sweetfynesse]

At my program, we use a patient tracking system, such that we know how long a patient has been in the ER prior to physician evaluation, how long the work-up takes, and how many patients a resident sees in a given shift. By looking at the screen we also know when labs have been drawn, when labs are ready, same for XR, CT, meds, etc. Now, we haven't been told how many patients we are expected to see during a given hour or shift, but I'm sure somebody somewhere is looking at the data.

If we get back logged, then the attending or senior resident will see patients to keep things moving. Or if a patient is there for a bogus complaint like med refills, then the attending or senior will get them out quickly. The only time we really become a drag is when we have a critically ill patient that is/or may become hemodynamically unstable. With those cases, we aren't allowed to pick up any new patients because we pretty much have to stay with them until they are either transferred, ICU/CCU team takes over, or they die. This is when the team approach is most useful.

As far as being overwhelmed, I don't think I've been overwhelmed yet. There are days that are busier than others, and days that you just don't feel like being at the hospital, but we have a great group of residents and attendings who understand what it was like being an intern, and so they try to make as enjoyable and learnable as they can for us.

 

[DrQuinn]

Originally posted by AVD
Those numbers sound high (ouch). Anybody else's programs give real numbers? (Do most programs have specific pt./hour number expectations for each level resident?)

Mine are 1 pt./hr as an intern, and 2pts./hr as a senior. (3 yr program)

Art

Our PD has told us that by the end of our intern year, we should be seeing 1.5 an hour... not that at this moment in time we should be seeing that. I think it takes a month or two in the ED just to get used to pushing yourself to the limit (and then being pushed farther to really get the learning experience).

At our program we don't have the luxury of any other interns/residents in the ED besides our new intern class... even then its just one intern. So in Nov, I will be the only EM intern on the whole month (around 20 shifts), with two or three other IM interns (who are horribly inefficient and use the month as vacation), along with 3-4 medical students (who can't write orders or write in the chart).

Our program is so new that the attendings have been used to seeing ALL the patients in the ED by themselves, having never had EM residents. They are not cutting down on the # of attendings at all, so even if I get backlogged, the attendings can easily pick up the slack. Our PD specifically told us we are not here to move the meat. I think that should be one thing you look at when interviewing. Some programs do expect you to MTM.

Q, DO

 

[Sessamoid]

1.5/hour sounds fast to me after the intern year to me as well. I don't think that's realistic in a center with high acuity. 2.5-3 pt/hour in a high acuity center for any but the superstar residents (i.e. previously trained in another field) is definitely not reasonable. 2.5 perhaps and if you're counting in cases they supervise.

That said, I had one absolutely nightmarish night shift where I saw 34 patients on an 8 hour shift. I never ever want to have another shift like that again. I was constantly carrying around 3 charts hoping to get just the minimum charting done. 3/hour is pretty busy even for a fast track shift.

 

[DocWagner]

Of course each ED is different, with acuity changes at each area of an ED...the higher the acuity, the lower the patient load and vice versa.
Smaller ED's for example may not get the high acuity patients and as a result, patient load may increase per resident (our program has 3 adult hospitals and 1 childrens hospital to manage, and the patient load at each facility is different).
Generally, an intern should see 1-1.2 patients per hour (adults) and no less than 1.5/hr for peds. It is traditionally expected to increase through residency up to 2-3/hr as a senior (if necessary).

 

[docB]

At my residency I was doing really well if I saw 2 pts per hour (that doesn't count the patients I was seeing jointly with the junior residents and the trauma team). One thing that is the case with most teaching programs is that the ED is inefficient in terms of getting info to the docs. At my program I had to go hound radiology to get my films back, hound the lab to get labs back, deal with all the social issues, all the transportation, etc. In private practice all that stuff is done for me so it bounced my pt per hr way up.

 

[SHOX]

Hey guys/gals,

Patients per hour is an important number to know, although it suffers the bias of not taking into account patient acuity (as mentioned in earlier emails).

Perhaps another number to look at is the number RVU(relative value units)/hours. The RVU to someextent takes into account accuity in that the higher the accuity the higher the RVU. This is a number based on billing levels; derived from medicare... most places should be tracking this. If you are a poor documenter this level suffers. In the real world this means dollars!

Throughout my residency I knew what my Pt's/hr and RVU/hr were and I encourage all others to do the same. It lets you know where you stand as far as the average for your PGY level and your worth overall as an ED doc.

SH

 

[AVD]

As an intern, do your senior residents throw patients at you, like "why don't you pick up room 3" regardless of your time to manage that patient?

I realize that it is important to be challenged, but I am also feeling at risk of managing patients poorly. Decreased learning for the sake of increased volume?

 

[Apollyon]

Originally posted by AVD
As an intern, do your senior residents throw patients at you, like "why don't you pick up room 3" regardless of your time to manage that patient?

Originally posted by Apollyon
In our program (and at others I've seen), the EM residents pick up the cases like everyone else, plus have cases assigned above and beyond (like traumas and transfers), versus in place of; that's just immersion and "trial by fire", the way I see it.

 

[DocWagner]

AVD...one of the skills you will learn is time management and multi-tasking, to learn it you must actively participate. Relax.
You are not the only one managing the case.
Yes, it is very likely you will have a cardiac arrest and status epilepticus arrive simultaneously...it is the way the ED works. To learn it you must experience it.