Should an academic ED be resident run?

[DeadCactus]

For whatever reason, this has been on my mind.

Should an academic emergency department be resident run? Resident run as in attendings do not see any patients on their own in that department and the department would not function without residents? This is in comparison to a department where throughput is not dependent on residents and attendings see some patients on their own in parallel to staffing resident patients. The fundamental argument being is it a better for residents to get experience being responsible for a department or is that an excuse to unnecessarily shift the focus from a training program to being a workhorse or cheap labor?

(Whether attendings should be required to work shifts in an ED without residents is another conversation.)

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[Dr Mantis Toboggan]

For whatever reason, this has been on my mind.

Should an academic emergency department be resident run? Resident run as in attendings do not see any patients on their own in that department and the department would not function without residents? This is in comparison to a department where throughput is not dependent on residents and attendings see some patients on their own in parallel to staffing resident patients. The fundamental argument being is it a better for residents to get experience being responsible for a department or is that an excuse to unnecessarily shift the focus from a training program to being a workhorse or cheap labor?

(Whether attendings should be required to work shifts in an ED without residents is another conversation.)

Would be better for the residents, but not the patients in my opinion.

Probably the sweet spot would be to have a few attendings available to help steer the ship but to have them spend absolutely zero time documenting anything. But that’s not realistic with malpractice and billing requirements etc.

 

[Rekt]

Zero value in completely resident run, unless you don't have the volume. Residents should be comfortable seeing 2+pph by mid pgy2 imo.

Nothing better than my attending taking the daily frequent flyer, the psych patient with zero educational value, patient needing dialysis only, etc etc for me to see the "real" patients.

 

[Angry Birds]

I am biased since mine was a resident run program. But, yes, I think that was best since it taught residents how to run the McDonalds and also freed up attendings to do some teaching, supervise, etc.
The frequent flyers, psych patients, etc. don't -- or shouldn't -- take much time for the resident to handle.

Attendings did, however, have to run the ER during weekly conference day.

 

[EctopicFetus]

I am biased since mine was a resident run program. But, yes, I think that was best since it taught residents how to run the McDonalds and also freed up attendings to do some teaching, supervise, etc.
The frequent flyers, psych patients, etc. don't -- or shouldn't -- take much time for the resident to handle.

Attendings did, however, have to run the ER during weekly conference day.

I trained in a resident run ED and now work in a non resident run ED. one of the big advantages of a non resident run ED is it allows docs to push themselves to see more people. I do think it likely takes away some teaching opportunities but thats the balance. I remember in residency what a nightmare the ED was when we showed up post conference and the attendings clearly had a poor grasp of running the place.

 

[Pigg-O-Stat]

I think the department should be completely resident run. That's the whole point of residency - to see as many patients as you can and learn how to run the department.

 

[PrisonPony13]

My program is basically resident run. There is one isolated pod (essentially fast track) that is 1 attending + APP, but the residents run the rest of the department. I think it should be that way. Some residents complain it's too much work and what not, but I feel the point of residency is to push yourself and learn how to handle it. The attendings have more time to teach because they're not seeing your patients + their own. As a student, I rotated at places where attendings had to see their own patients and they did much less teaching and the residents struggled with handling more than 1-1.5 PPH.

 

[Mr. Vandemar]

Where I trained it was resident run which I thought worked well in terms of our education. On the other hand, now that I’m in the community it’s clear some of my attendings hadn’t really practiced medicine/worked in probably decades and it’d probably do them some good…

 

[Lexdiamondz]

A resident-run ER is definitely optimal for the resident-education side of things. That being said, for attendings unless you have a side gig at a community site you are likely to experience some skill atrophy. I know of more than a handful of academic EM folks who havent done a reduction, a CVL or intubated in over 5 years

 

[southerndoc]

Does RRC allow patients to be seen by a resident only?

 

[Franzd'Epinay]

My attendings would often see 0 patients on the pods with residents. When things got insane, most attendings would pick up a few of the simple patients. If we were coming into a ****show, some attendings would take the babysitting patients for sign out (repeat trop, drunk waiting to sober up, etc). Some attendings would never see a patient on their own, though.

It made sense. Everyone was satisfied.

 

[MedicineZ0Z]

A resident-run ER is definitely optimal for the resident-education side of things. That being said, for attendings unless you have a side gig at a community site you are likely to experience some skill atrophy. I know of more than a handful of academic EM folks who havent done a reduction, a CVL or intubated in over 5 years

That's also a thing in the ICU. I'm not sure there's a solution for it either.

 

[TheComebacKid]

When I was a resident, if my attending picked up a patient, I felt totally insulted and inadequate and felt like I needed to up my game. This is part of the culture of medicine, and while it's great to push yourself to see more patients, this type of mentality also really contributes to resident depression/burnout/lack of empathy etc.

As an academic attending right now, depending on which area I work in, I routinely have 20-30 patients in a single pod supervising 2-3 residents. While the residents think I'm just sitting there coasting because I'm not writing the notes and calling consults/putting in orders, there is a high degree of cognitive burden juggling that many patients and keeping things on track. I'm following up on critical labs, imaging, supervising procedures, signing off EKGs, seeing all the same patients that they are seeing (granted spending less time with them), reviewing their ultrasounds, taking transfer calls, talking to the charge nurse about whatever fires need to be put out, all the while trying to throw in some teaching opportunities. In my current set up, picking up a patient and seeing it independently would be less than ideal given all the things you juggle.

I can say from my perspective, its was easier to moonlight as a fellow in the community where I carried 12-14 patients independently on my own, than to supervise 2-3 residents (including interns, off service psychiatry residents) in a pod with 30 patients. It's much easier to do the things on your own, than it is to cross check what everyone else is doing. You have to know who to trust, and not all residents are the same.

The next day my inbox is filled with tons of notes, all with various degrees of documentation, some good, some literally with one sentence on a 70 year old patient with chest pain that we sent home without any real degree of MDM/thought process that I have to go back in and addend. Plus I have to generate a billable chart, some residents are quite bad at this and get poor training in it, unfortunately.

That being said, overall, I love working with residents, and would not work in a place without them. It gives a little bit more meaning to the job if you feel like you get the opportunity to pass something on to the next generation. It's also nice to take them out after shift for some food/drinks and see how happy they are to get a break from the hospital. The vast majority of residents at the program I work at give it their all and are a pleasure to work with.

 

[TheComebacKid]

Also in terms of procedural atrophy, 100% a thing in academics. That being said, I don't see another way. There is no way I can justify intubating a patient when I have an intern who needs to be coached through one.

That being said, where I did residency, we did have a month for attending procedures, where the attendings got first dibs on all procedures. Most of them would give them away still, but still, you'd have an attending who would take a tube from you and it drove me nuts.

 

[Arcan57]

Mid-2nd years being universally comfortable with 2+ pph is fantasy land. Seeing 2 pph requires a level of throughput on the part of the facility that is atypical for academic facilities, especially resident run EDs. What's more important is the ability to start workup and stabilization on 4 sick patients in 1 hour, or be able to deal with two critically ill patients at the same time.

 

[BoardingDoc]

A resident-run ER is definitely optimal for the resident-education side of things. That being said, for attendings unless you have a side gig at a community site you are likely to experience some skill atrophy. I know of more than a handful of academic EM folks who havent done a reduction, a CVL or intubated in over 5 years

Agreed. I went to an essentially resident run program. I had long since graduated at this point, but I subsequently heard about a case that went to M+M. The attending was working at one of the satellite hospitals and only had an intern working with him that day. Patient came in who obviously needed to be tubed but was transferred on BiPAP. The patient ultimately had some issues, and at M+M it was asked why they didn't intubate before transfer. The response was: "The intern hasn't learned how to intubate yet, and I haven't intubated anyone in at least 5 years and didn't feel comfortable doing so."

The honesty was nice. The actual events, not so much.

 

[p1acebo]

When I was a resident, if my attending picked up a patient, I felt totally insulted and inadequate and felt like I needed to up my game. This is part of the culture of medicine, and while it's great to push yourself to see more patients, this type of mentality also really contributes to resident depression/burnout/lack of empathy etc.

As an academic attending right now, depending on which area I work in, I routinely have 20-30 patients in a single pod supervising 2-3 residents. While the residents think I'm just sitting there coasting because I'm not writing the notes and calling consults/putting in orders, there is a high degree of cognitive burden juggling that many patients and keeping things on track. I'm following up on critical labs, imaging, supervising procedures, signing off EKGs, seeing all the same patients that they are seeing (granted spending less time with them), reviewing their ultrasounds, taking transfer calls, talking to the charge nurse about whatever fires need to be put out, all the while trying to throw in some teaching opportunities. In my current set up, picking up a patient and seeing it independently would be less than ideal given all the things you juggle.

I can say from my perspective, its was easier to moonlight as a fellow in the community where I carried 12-14 patients independently on my own, than to supervise 2-3 residents (including interns, off service psychiatry residents) in a pod with 30 patients. It's much easier to do the things on your own, than it is to cross check what everyone else is doing. You have to know who to trust, and not all residents are the same.

The next day my inbox is filled with tons of notes, all with various degrees of documentation, some good, some literally with one sentence on a 70 year old patient with chest pain that we sent home without any real degree of MDM/thought process that I have to go back in and addend. Plus I have to generate a billable chart, some residents are quite bad at this and get poor training in it, unfortunately.

That being said, overall, I love working with residents, and would not work in a place without them. It gives a little bit more meaning to the job if you feel like you get the opportunity to pass something on to the next generation. It's also nice to take them out after shift for some food/drinks and see how happy they are to get a break from the hospital. The vast majority of residents at the program I work at give it their all and are a pleasure to work with.

I had the same experience and mentality as a resident, we took pride in trying to run the department ourselves without the crutch of the attending helping us with disposition. I trained at a large institution (~135,000 annual visits), some of the attendings would pick up here and there, and some would not even if there was 7 in the rack.

I do disagree with you about the job being easier managing your own patients with less volume vs managing residents with large volume. While you are supervising multiple residents on shift, my experience has been having a mix of senior residents, interns, and off service residents. Sure you have to hand hold the intern and off service residents, but they take care of the time consuming tasks (documenting, majority of patient interaction, speaking with consultants, etc). It’s also their responsibility to take ownership of difficult patients they would have, and for the attending to step in only when necessary.

When seeing patients on your own at a community shop it literally only takes one or two difficult (behavioral) or complicated patients to bog you down. Not to mention the empathy and mental fatigue of dealing with difficult patients or consultants.

I know every place is different, but I’m willing to bet most academic gigs are easier and lead to less burnout than community gigs.

 

[lucid_leprechaun]

I like the resident run model but also that’s what I know. Gives ownership and helps you grow. Not sure how it compares but our graduates are all capable at moving a department.

 

[Angry Birds]

Agreed. I went to an essentially resident run program. I had long since graduated at this point, but I subsequently heard about a case that went to M+M. The attending was working at one of the satellite hospitals and only had an intern working with him that day. Patient came in who obviously needed to be tubed but was transferred on BiPAP. The patient ultimately had some issues, and at M+M it was asked why they didn't intubate before transfer. The response was: "The intern hasn't learned how to intubate yet, and I haven't intubated anyone in at least 5 years and didn't feel comfortable doing so."

The honesty was nice. The actual events, not so much.

Well, that's nuts. Academic attendings should then have to work at least one satellite shift to make sure they don't atrophy this bad.

 

[WilcoWorld]

Resident run EDs should be staffed by attendings who are capable of bailing out the residents when they get into trouble. That's not the same as expecting the department to run exactly the same without the residents. When all the residents are away for retreat/conference/in service, the department should increase staffing to match volume and the attendings should be capable of getting their white coats a bit dirty.

 

[RoyBasch]

Zero value in completely resident run, unless you don't have the volume. Residents should be comfortable seeing 2+pph by mid pgy2 imo.

Nothing better than my attending taking the daily frequent flyer, the psych patient with zero educational value, patient needing dialysis only, etc etc for me to see the "real" patients.

The "zero educational value" patients come to real community attending-only ERs in high volumes. Learning how to see and manage these patients efficiently (including while simultaneously managing real high complexity and sick patients) is a "skill" that requires practice.

But yes I do think it's valuable when attendings pitch in and see some patients individually to help ER flow when it is busy.

 

[Angry Birds]

The "zero educational value" patients come to real community attending-only ERs in high volumes. Learning how to see and manage these patients efficiently (including while simultaneously managing real high complexity and sick patients) is a "skill" that requires practice.

Co-signed

 

[Rekt]

The "zero educational value" patients come to real community attending-only ERs in high volumes. Learning how to see and manage these patients efficiently (including while simultaneously managing real high complexity and sick patients) is a "skill" that requires practice.

But yes I do think it's valuable when attendings pitch in and see some patients individually to help ER flow when it is busy.

Right but people ignoring the volume part my statement.

People saying you need resident run for volume make no sense either. There's always always patients waiting to be picked up. (We see about 90% of pts still anyway in 100k volume) I almost never see less than 18-20pts in 8 hours. Often seeing 22-24 and still walk out on time. I have entire chart macros for these nonsense patients. It's still a waste of my time whether that amount of times 5 seconds or 5 minutes.

There's academic "powerhouses" out there that can barely see 1pph as pgy3s. Efficiency and speed is really the main thing that separates us from mid levels and non ABEM. Hard truth.

 

[Brigade4Radiant]

Resident run EDs should be staffed by attendings who are capable of bailing out the residents when they get into trouble. That's not the same as expecting the department to run exactly the same without the residents. When all the residents are away for retreat/conference/in service, the department should increase staffing to match volume and the attendings should be capable of getting their white coats a bit dirty.

Well the thing is being an academic attending you will have skill atrophy because the senior residents each year do the procedures. In my residency during conference days they hired some prn clinical staff that work other places but core facilty would never work during inservice or for retreats.

 

[RoyBasch]

Right but people ignoring the volume part my statement.

People saying you need resident run for volume make no sense either. There's always always patients waiting to be picked up. (We see about 90% of pts still anyway in 100k volume) I almost never see less than 18-20pts in 8 hours. Often seeing 22-24 and still walk out on time. I have entire chart macros for these nonsense patients. It's still a waste of my time whether that amount of times 5 seconds or 5 minutes.

There's academic "powerhouses" out there that can barely see 1pph as pgy3s. Efficiency and speed is really the main thing that separates us from mid levels and non ABEM. Hard truth.

Just for a little context, I am primarily a community based physician, I work 90%+ of my shifts at community hospitals with no residents, and the majority of those shifts are single coverage. I pick up 1-2 shifts/month as adjunct faculty at a university of residency program. I probably see more patients independently when I work at the university than my full time academic colleagues probably because I am used to seeing patients independently.

You yourself say there are "academic power houses" graduates that cannot see more than 1pph. How do you think you learn to move through patients efficiently? By having to move through large numbers of patients. Moving through low acuity patients efficiently is its own skill that is completely different than learning the right medical decision making in complicated and sick patients. This skill merits specific time and attention to learn.

Also the "dao" of "non sense patients" is learning to find the needles in haystacks. I recall a "psych patient" one of my residents saw. I have no doubt their history and exam were very cursory. The patient was acting somewhat agitated and the symptoms were summarily attributed to drug intoxication or decompensated mental illness. When I went to supervise on the patient I noted he had a hematoma on his head. Brief further interrogation revealed the patient had fallen down the stairs. I ordered a CT head which showed a large acute SDH. Patient decompensated and was intubated within the hour.

I expect for that resident this "zero educational value" case was not zero educational value. I hope there was an important lesson for them on how to see these patients quickly but still execute one of the fundamental responsibilities and values of emergency physicians, which is detecting life threatening emergencies in initially stable-appearing patients.

The only way to learn how to find these needles in haystack cases is to see large volumes of these cases and develop pattern recognition skills. My point is what you presume to be "zero educational value" cases may provide more value to you than you know by giving you a "denominator" of patient baselines so you can find the rare pathologies or "numerators" and the subtle differences between the two.

Again: If the resident is seeing 2+pph and the waiting room is backed up, and wait times are punishing, I am more than happy to jump in and see people. I do not feel it is my "privilege" to see no patients independently, write no complete notes, or make no phone calls. BUT, I do think there is value in residents seeing volume and feeling the "crush" a little bit to move. Again you are in residency to learn, but the patients are at the hospital to get care, and their care should not suffer too much for your learning experience.

 

[WilcoWorld]

Well the thing is being an academic attending you will have skill atrophy because the senior residents each year do the procedures. In my residency during conference days they hired some prn clinical staff that work other places but core facilty would never work during inservice or for retreats.

I'm a clinical core faculty at a university program who works during inservice/retreats and I bail out my seniors when they can't get a procedure.

I'm not saying this is the way it is everywhere. I'm saying it's possible. It requires that the faculty make choices and take actions to avoid atrophy, but it's doable.

 

[Angry Birds]

I'm a clinical core faculty at a university program who works during inservice/retreats and I bail out my seniors when they can't get a procedure.

On a scale of 1-10, how embarrassed are they when you have to do that?

 

[Apollyon]

On a scale of 1-10, how embarrassed are they when you have to do that?

When I was a resident, we had a faculty member come aboard who had been a resident at Geisinger (didn't come to us directly from residency). This a****** took at least one procedure from me. This was a supraclavicular subclavian line. (There may have been others that I do not recall.) I hadn't tried and failed. He just did it. My PD was NOT happy with that. I don't even know where he is now.

 

[Kryptocoin]

I've had an attending rescue me from a failed tube as an intern. I was pretty embarrassed but happy that I had an awesome attending at my side.
Now some attendings can be jerks and berate a resident for failing a procedure. I commonly see that with surgery attendings though.

 

[CliveStaples]

I probably bail a "failed" intubation once a quarter or so, and usually from an intern. Probably as similar number of assists on central/arterial lines. At the beginning of the year I get my hands in there on somebody's first chest tube or paracentesis. Between those experiences and working during resident conferences or occasionally at our community hub, I don't see myself atrophying too quickly. That said, some of the faculty don't ever work during resident conference or at our community site and I would be more nervous about my hands-on skills in that situation.

I don't take procedures away from my residents, but I will say that the way that I think I jump in sooner than a few of my colleagues, and I don't think I'm being too conservative. If somebody is desaturating to the 70s during an intubation and I'm not getting the feeling that my resident isn't on the cusp of "figuring it out," then I'm going to step in.

 

[TheComebacKid]

I had the same experience and mentality as a resident, we took pride in trying to run the department ourselves without the crutch of the attending helping us with disposition. I trained at a large institution (~135,000 annual visits), some of the attendings would pick up here and there, and some would not even if there was 7 in the rack.

I do disagree with you about the job being easier managing your own patients with less volume vs managing residents with large volume. While you are supervising multiple residents on shift, my experience has been having a mix of senior residents, interns, and off service residents. Sure you have to hand hold the intern and off service residents, but they take care of the time consuming tasks (documenting, majority of patient interaction, speaking with consultants, etc). It’s also their responsibility to take ownership of difficult patients they would have, and for the attending to step in only when necessary.

When seeing patients on your own at a community shop it literally only takes one or two difficult (behavioral) or complicated patients to bog you down. Not to mention the empathy and mental fatigue of dealing with difficult patients or consultants.

I know every place is different, but I’m willing to bet most academic gigs are easier and lead to less burnout than community gigs.

Long term, yes, likely less burnout in academics. Residents do shield you from some challenging patient and consultant interactions. And thank goodness for them doing lac repairs.

That being said, from my perspective... when I put in an order, I know its in, and I'm done, and I don't have to go back and crosscheck. With residents, I tell them to do something, and often times they forget, and if I forget to double check their work, it becomes an issue. Leads to dispo delays, and sometimes patient care issues.

I had a colleague who was supervising a resident placing a central line. Sick patient rolled in, he stepped out of the room to briefly lay eyes on the patient. Came back in the room, guide wire was gone and in the vessel.

Perhaps it was faulty supervision on his part, but it's not always easy being 100% responsible for the actions of others. Granted, a hard working and seasoned senior resident can make your shift go by very smoothly, it can also be more challenging. Senior residents are incredibly confident, especially right before they graduate... They undersell a lot of patients, want to discharge everyone, downplay symptoms etc. Having to sift through that bias, I find, makes my job more difficult.

Regardless, I'd take the worst resident than having to supervise a midlevel any day.

 

[NicksMD]

Resident run departments where the flow is poor and the department is inadequately staffed is a recipe for burnout and patient safety disasters. I don’t know who convinced you guys otherwise. Seeing 5+ pph per resident has no educational value. Moving the meat is definitely a skilled to be learned but what community places has that volume? It’s more beneficial for the department than resident education.

 

[BoardingDoc]

I had a colleague who was supervising a resident placing a central line. Sick patient rolled in, he stepped out of the room to briefly lay eyes on the patient. Came back in the room, guide wire was gone and in the vessel.

This sounds like a rather subpar resident. Unless you're in a facility where there is a coding patient rolling in and you are the only doc there... why in the hell would you stop a CVL mid procedure (forget for the moment that you're at the part where you have the wire in as that's just icing on the s*** cake) in order to go "lay eyes" on a patient? That's literally idiotic.

Regardless, I'd take the worst resident than having to supervise a midlevel any day.

Not a midlevel defender here, but I'm gonna have to disagree with you on that one. You have no obligation to provide teaching opportunities for midlevels. You do for residents. I would much rather tell the midlevel: No, go do this and then please sew up this screaming 2 year old that just rolled in, as opposed to dealing with the fact that resident Dr. McAssassin was busy trying to place an ultrasound guided IV into a patient with a blunt tip filler needle (I actually saw an intern try this when I was a senior resident)

I also may have a skewed view as I work at a shop where we have total control over what PAs we hire/fire and how they operate.

 

[Angry Birds]

This sounds like a rather subpar resident. Unless you're in a facility where there is a coding patient rolling in and you are the only doc there... why in the hell would you stop a CVL mid procedure (forget for the moment that you're at the part where you have the wire in as that's just icing on the s*** cake) in order to go "lay eyes" on a patient? That's literally idiotic.

I was subpar in procedures during residency (a deficit I had to furiously make up after residency) but even I would not have been so stupid to leave in the middle of a central line.

This lost guide wire thing happened to another resident ... I don't understand how that can happen. The guide wire is so long.

 

[RoyBasch]

This sounds like a rather subpar resident. Unless you're in a facility where there is a coding patient rolling in and you are the only doc there... why in the hell would you stop a CVL mid procedure (forget for the moment that you're at the part where you have the wire in as that's just icing on the s*** cake) in order to go "lay eyes" on a patient? That's literally idiotic.

A lamentable situation, that fortunately can usually be remedied by IR without longterm sequelae for the patient. That being said, lost guide wires are a known complication of central lines and a known beginner mistake. It is not a mark of a sub-par resident that they made a procedural error commensurate with their ability. Beginners make beginner mistakes. We were all beginners once and you gotta start somewhere.

The attending probably should have been continuously supervising during these critical portions in the procedure. That being said, if a really critical patient comes in and they are the only attending available to do so, then that may require their attention. The nature of EM is that these "Sophie's choice" situations occur occasionally. I suppose the real "fault" here is the system, which is not adequately staffed for an attending to adequately supervise a critical procedure and a different critical patient. But that being said, I'm sure the vast majority of us work in systems with inadequate coverage when surges happen as most department staffing is dictated by the average, not these (frequent) exceptional situations.

 

[Apollyon]

The nature of EM is that these "Sophie's choice" situations occur occasionally.

True story: when I was a resident, there was a resident in another specialty that was closer than further away related to the guy that wrote "Sophie's Choice"!

Although, truth be told, I think Sophie's choice had more gravitas.

 

[Angry Birds]

A lamentable situation, that fortunately can usually be remedied by IR without longterm sequelae for the patient. That being said, lost guide wires are a known complication of central lines and a known beginner mistake. It is not a mark of a sub-par resident that they made a procedural error commensurate with their ability. Beginners make beginner mistakes. We were all beginners once and you gotta start somewhere.

The attending probably should have been continuously supervising during these critical portions in the procedure. That being said, if a really critical patient comes in and they are the only attending available to do so, then that may require their attention. The nature of EM is that these "Sophie's choice" situations occur occasionally. I suppose the real "fault" here is the system, which is not adequately staffed for an attending to adequately supervise a critical procedure and a different critical patient. But that being said, I'm sure the vast majority of us work in systems with inadequate coverage when surges happen as most department staffing is dictated by the average, not these (frequent) exceptional situations.

I'm with you on the fact that mistakes happen, especially with juniors... BUT it really does show a profound lack of judgment to walk out of a procedure like that instead of just yelling out, "I'm in the middle of a central line right now...!"

But, like you, I wonder where the senior was if indeed this person was an intern!

 

[xaelia]

Sounds like the consensus above is basically describing my ED in New Zealand.

Trainee-run – although, there really need to be *more* of them to run it with our current volumes – with the FACEMs around as consultants.

The tension arises when the volume/acuity rises above the capacity of the trainee staff, leading to that general decompensation when the consultant has a patient load sucking away from all the oversight and flow necessary.

 

[The Knife & Gun Club]

Ideally a residency would have a mix of “resident run” areas and non-resident run areas/sites. At least that’s the set up we have, and I like it. We have our resident run pod that’s staffed with 3 residents + 1 attending, then other pods that are 2+2 format. Both have pros and cons but I don’t think the learning increases that much from usually —> always running the pod.

Also pod makeup matters - you’re never gonna get to 3+ PPH as a resident if the pod only sees ESI 1-3 with relatively few “easy cases” like the young otherwise heathy gastroenteritis or non-displaced ankle fracture.

 

[Groove]

My residency was at a 4y level 1 trauma center and was completely resident run. In hindsight, I thought this was a superior way to gain experience and autonomy. Nowadays, I think a completely resident run ED is not very realistic with increasing focus placed on metrics and let's face it...if it's a CMG run residency, it most definitely will not be 100% resident run because they want the numbers to look good. I currently am faculty at a CMG residency and at first, I thought having attendings working alongside the residents, helping them maintain efficiency would be a bad thing but it's proved to be the opposite. I think it's actually good for them to see us in action, hear our consults, see the tips and tricks in our strategy to management of the board. I never heard an attending talk to a consultant in residency or was able to watch them manage anything. Our current residents seem to get a grasp of managing the ED with maximum efficiency much more easily than I remember back in my residency days and the only thing I can attribute it to is the change in environment. It certainly doesn't hurt them as most of them are very good.

The only thing I've noticed is that since they are not running all the patients, they don't get overloaded very often and can keep their pt load to a comfortable number. At first, I thought this would hurt them once graduated when they are expected to see large boluses of patients but our current grads hit the ground running just as efficient and just as fast as I did coming out.

 

[DeadCactus]

I think it's worth noting that residents seeing inadequate or excessive volume is a staffing issue and not necessarily the same question as whether the department should be resident run with a resident expected to see every patient that comes through the department.