Resdident-run emergency departments

[WallowaWanderer]

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I did some searches on this but didn't find anything. The closest I could find was "Programs where the ED dominates" which wasn't quite what I was looking for.

I'm looking for a list of programs where there is a significant emphasis on senior residents having supervisory roles in the department . . . i.e. teaching and taking presentations from students/interns, managing emergency department flow, coordinating care for the majority of patients in the department, giving lectures to students and interns, etc. It doesn't matter to me if they are well known or little known programs, or what "tier" they are in.

I was just reading the recent reviews of BIDMC, and I know that Denver operates this way as well. That's the model I am thinking of with this post. So what do you guys think - What other programs are like this?

 

[annie5644]

great question. i think a lot of residencies have graded responsibilities such that by the end of your training, you are essentially acting like an attg, running the dept and supervising jr residents. i would def say that is a huge plus for any program. i know that at haemr (brigham and mass general), the 3rd or 4th year is running the department and we present all cases to them, they supervise all jr residents, know what's coming in from ems, etc. basically act like an attg and are responsible for every pt in their dept.

 

[awdc]

I'm looking for a list of programs where there is a significant emphasis on senior residents having supervisory roles in the department . . . i.e. teaching and taking presentations from students/interns, managing emergency department flow, coordinating care for the majority of patients in the department, giving lectures to students and interns, etc. It doesn't matter to me if they are well known or little known programs, or what "tier" they are in.

Rest assured that you'll find that virtually every program is run just as you described above. I really tried to think of a program where this does not happen and I can't come up with any examples.

 

[WallowaWanderer]

Rest assured that you'll find that virtually every program is run just as you described above. I really tried to think of a program where this does not happen and I can't come up with any examples.

Of the 4 departments I rotated, 2 worked as I described and 2 did not. But it's so hard to find out unless you rotate there. That's why I'm looking for folks to help me make a list.

 

[southerndoc]

Most 4-year programs will give you a heavy emphasis on teaching and academics. At Yale, the third year resident spends 40% of his/her shifts in a supervisory role doing just as you describe (managing the ED; receiving presentations from junior residents, interns, and students). The fourth year resident spends 70% of his/her time in this role. The remaining time is spent staffing a critical care area (60% for the PGY-3, 30% for the PGY-4).

The critical care shifts are 10 hours each (either 7:30a-5:30p or 4:30p-2:30a), and the supervisory shifts are 9 hours each (7a-4p, 3p-12a, 11p-8a). All supervisory shifts are on the north side of our ED. During supervisory shifts, the supervising resident sees patients on his or her own only if the ED is really busy. I usually will pick up a few patients on my own just because I get bored easily and also want to give hard working interns an occasional break. However, I know many residents who never pick up a patient on their own during a supervising shift.

Despite the residents "running" the ED, there is still an attending that must see every patient. During your first few months of supervising, the attending will pretty much run the show. After a while, you gain confidence and the attendings turn over ED management to you and will only intervene when necessary. We have 24-hour attending coverage on the north side, 10-hour dedicated north critical care attending coverage, 10-hour dedicated south critical care attending coverage, and an additional 10-hours of south attending coverage. During peak times we have four attendings on duty at one time, and during the wee hours of the morning (2a-7:30a) we have only one attending.

I really like the way our program is set up. It definitely trains one very well for a job in academics. However, I am sure that my program is not unique. There are probably tons of programs out there that train the same way.

 

[totalbodypain]

I did some searches on this but didn't find anything. The closest I could find was "Programs where the ED dominates" which wasn't quite what I was looking for.

I'm looking for a list of programs where there is a significant emphasis on senior residents having supervisory roles in the department . . . i.e. teaching and taking presentations from students/interns, managing emergency department flow, coordinating care for the majority of patients in the department, giving lectures to students and interns, etc. It doesn't matter to me if they are well known or little known programs, or what "tier" they are in.

I was just reading the recent reviews of BIDMC, and I know that Denver operates this way as well. That's the model I am thinking of with this post. So what do you guys think - What other programs are like this?

Graduated responsibility and leveled responsibility in the ED is acutally something that is required by the RRC for a program. It seems to occur naturally in the county/city hospital and non private university type setting but has to be in place in some shape or form in all programs. Some hospitals (notably privates) have to twist a little more to get this in place but it is a requirement.

 

[EM_Rebuilder]

Here in MS, everyone presents to the attendings.....MSIV to PGYIV. Upper level residents are there for procedure help/assitance, and other questions (sideline consults?).


I would NOT like being at a place where a jr level checks out to the sr level resident. Lets be honest, will I learn more from checking out/discussing to a 4th year resident, or a 20th year attending?


As far as 'learning how to run a complete department', how better to learn that than to get paid well doing it? I think moonlighting is what toughens your bones for doing that. Start slow and small, and work up in size/patient load.


I am just a lowly intern so take it for what it costs ya...

 

[totalbodypain]

You actually may be learning more if you are presenting to a senior. The attending is involved in every case no matter what either way. If you free up your attending (by utilizing your senior to worry about the initial work up and the basics of the case) then you leave your attending with time to point out the teaching points/areas that could be improved upon and to spend additional time on didactics. You also at the same time are training your seniors to lead the ER/teach and thirdly are meeting a basic RRC requirement. Additionally working in a busy county type hospital this provides us with a sort of saftey net. No attending likes to find out there case is being presented as a M&M and find out that the 1st year resident had the patient a good solid hour before any type of presentation was given to the Attending. This way your seniors are involved very early because they help to assign cases and also help to ensure that critical steps are not missed. The attendings are made aware of any sick cases and then they discuss each case individually with the juniors (sick or not sick) along with teaching points.

 

[ditch doctor]

In my 4th year I rotated at a bunch of different programs and New Orleans puts you "in charge" the most. New Orleans has you managing the whole ED beginning your 2nd year. The interns see patients and check out to you and you in turn check out to staff. From your second year on you are responsible for all patients in the ED and you function as charge resident. Only in your intern year are you "only" managing 9 or 10 patients. If you want a place that emphasizes autonomy they are it.

 

[dlung]

I ran my own 6-bed Casualty unit in Kenya. It was a blast.

Good luck finding total resident autonomy in the States. I assume because of liability and having a high standard of care, places where the residents really run the ED are disappearing. From what I've heard through the grapevine, even the Jail ED at LA County (traditionally run by a 3rd year resident) is going to have attending coverage soon. However, a more interesting and difficult query that you seem to be interested in is what programs have a more cowboy/'hand-off' environment... that's going to be by word of mouth and personal experience. But, your odds are better with a county hospital.

 

[WallowaWanderer]

Bump

So far we have have HAEMR and Yale. Seems like everyone's pretty quiet about this. Any other programs you guys would add to the list?

 

[zinjanthropus]

How about.....

jacksonville
emory
louisville
maricopa

 

[Janders]

First hand experience wise, I can fully agree that Jax is a 3yr program where the residents run the ED.

 

[Egon]

Mt Sinai NYC
Jacobi

At Newark BI the seniors run rounds, flow, and guide med students and interns on their cases

 

[jaboy]

At U Mass they have a few months were you are the supervisor and run the department as opposed to seeing patients for the first time. Everyone presents to you.

 

[WallowaWanderer]

So far:

jacksonville
emory
louisville
maricopa
Sinai
Jacobi
Denver

Any others you guys know of?

 

[totalbodypain]

So far:

jacksonville
emory
louisville
maricopa
Sinai
Jacobi
Denver

Any others you guys know of?

Again, I would be more interested to know which programs don't versus those that do. I would be willing to bet the latter is in the minority. Most programs have some sort of progressive responsibility or graduated responsibility built into the structure of the program and the way in which the ED functions. My program certainly does but again I have heard of few that don't.

 

[WallowaWanderer]

Again, I would be more interested to know which programs don't versus those that do. I would be willing to bet the latter is in the minority. Most programs have some sort of progressive responsibility or graduated responsibility built into the structure of the program and the way in which the ED functions. My program certainly does but again I have heard of few that don't.

I know that this is supposed to be a feature of all programs to an extent (although I saw no evidence of it on 2/4 of my ED rotations), I'm Looking for the programs that are specifically known for residents having tons of responsibility in and actually running the department. Just like all programs have some form of ultrasound but only a few have an excellent ultrasound program, I'm interested in learning what programs put residents in charge the most.

 

[southerndoc]

I know that this is supposed to be a feature of all programs to an extent (although I saw no evidence of it on 2/4 of my ED rotations), I'm Looking for the programs that are specifically known for residents having tons of responsibility in and actually running the department. Just like all programs have some form of ultrasound but only a few have an excellent ultrasound program, I'm interested in learning what programs put residents in charge the most.

I've heard that Cincinnati has such a setup.

 

[NinerNiner999]

Hopkins - graded responsibility, team leadership PGY 2,3 and ED management and education PGY3. Good program setup (but I may be biased).

 

[8744]

I did some searches on this but didn't find anything. The closest I could find was "Programs where the ED dominates" which wasn't quite what I was looking for.

I'm looking for a list of programs where there is a significant emphasis on senior residents having supervisory roles in the department . . . i.e. teaching and taking presentations from students/interns, managing emergency department flow, coordinating care for the majority of patients in the department, giving lectures to students and interns, etc. It doesn't matter to me if they are well known or little known programs, or what "tier" they are in.

I was just reading the recent reviews of BIDMC, and I know that Denver operates this way as well. That's the model I am thinking of with this post. So what do you guys think - What other programs are like this?

This is just my opinion, and applicable to only me, but I have no desire to manage the department in the sense that I have to supervise medical students and junior residents. I do not want to prepare lectures and I do not want to be presented to by anybody. It is about all that I can handle to finish my shifts and do a little moonlighting without the extra hassle.

In fact, as much as I like my program and our attendings, my fondest desire in 18 months is to get a job at a small, community-type Emergency Department and never see another medical student, resident, or academic physician again.

But that's just me.

 

[8744]

And I don't know what you all mean by "managing the department." Patients come in, pick up chart, repeat. The only thing that really matters is being able to prioritize and keep things flowing which is not enhanced by getting presentations from medical students. Don't we just sort of manage one patient at a time?

I think by manage you all mean, "Prepare for a career in academics."

 

[southerndoc]

And I don't know what you all mean by "managing the department." Patients come in, pick up chart, repeat. The only thing that really matters is being able to prioritize and keep things flowing which is not enhanced by getting presentations from medical students. Don't we just sort of manage one patient at a time?

I think by manage you all mean, "Prepare for a career in academics."

Managing the department: releasing patients to go to the floor when their bed is ready v. keeping them in the ED for other testing (CT, lab, etc.), releasing patients for discharge when you get the feeling they are ready for discharge (i.e., patients getting fluids for rehydration), telling triage where to place patients (is it a trauma or not, does it need a critical care bed or not), etc.

 

[WallowaWanderer]

I think by manage you all mean, "Prepare for a career in academics."

Respectfully, that is not what I mean. Panda, I think that's awesome that you know you want to work in the community and that you don't want extra responsibilities in residency. I totally respect that, and . . . maybe I'll feel the same way some day . . . maybe not.

I'm not trying to say that resident-run ED's are the best environments for everyone to train in - what I am saying is it's what I want.

I think if I try to explain what I mean by "resident run" it might create a big debate, which isn't what I was looking for. So I'm not going to.

 

[zinjanthropus]

Respectfully, that is not what I mean. Panda, I think that's awesome that you know you want to work in the community and that you don't want extra responsibilities in residency. I totally respect that, and . . . maybe I'll feel the same way some day . . . maybe not.

I'm not trying to say that resident-run ED's are the best environments for everyone to train in - what I am saying is it's what I want.

I think if I try to explain what I mean by "resident run" it might create a big debate, which isn't what I was looking for. So I'm not going to.

besides, i think those of us who have rotated through, talked to residents from, or seen a lot of different EDs on the interview trail, have a pretty good idea of what this means

 

[NinerNiner999]

Trust me- you may not see the benefits of listening to presentations but it is a critical skill- especially in the community, where you will likely have PAs and NPs presenting patients to you with less training than the interns and residents you work with. These presentations are vital to your ability to be efficient and see your own patients. The community in many aspects can be much more difficult than academics. IMHO learning basic emergency medicine is the minimum for any job, but exposure to as many of the "annoying" aspects of this field in residency will only make you better prepared to handle things when those annoyances become real-life obstacles on a daily basis.

 

[8744]

Trust me- you may not see the benefits of listening to presentations but it is a critical skill- especially in the community, where you will likely have PAs and NPs presenting patients to you with less training than the interns and residents you work with. These presentations are vital to your ability to be efficient and see your own patients. The community in many aspects can be much more difficult than academics. IMHO learning basic emergency medicine is the minimum for any job, but exposure to as many of the "annoying" aspects of this field in residency will only make you better prepared to handle things when those annoyances become real-life obstacles on a daily basis.

You make good points. Let me reiterate, however, that my fondest hope once I finish residency and as much as I like my program and our attendings, is to get as far away from academic medicine as I possibly can. No offense meant to anyone because I certainly admire and respect most of the academic physicians I have met but it is just not for me.

At my program, we do not get presentions from medical students or junior residents, all of which go through the attending so our experience with this is limited to the occasional off-service rotation.

 

[NinerNiner999]

I hear you- that's why I went into the community- and so far it is great. 🙂

 

[JackBauERfan]

I think in general you may get 'resident run EDs' more in the county type of programs, but I would think any ED residency would have a laddered system where the senior overseeing a lot more stuff. And anywhere for billing the attendings have to have seen the patient even if its eyeballing them...

 

[mar8d]

From the interview trail, you can add these to the list...

Maryland
Carolinas Medical Center