Thoughts on training at a low acuity program?

[ihearttriangles]

I was wondering if any residents or attendings had any advice on how important it is to train at a a high acuity program. I recently interviewed at a program that was almost a perfect fit in that it was in a great city, close to family, great for husband's career, etc... however, it was apparent that the acuity was extremely low. A friend of a friend is a nurse in said hospital, and also has experience working in the other program in town's ED, and said that the other ED makes this ED look like an "urgent care." (sorry if this is confusing but I'm doing my best to stay vague) She said they barely get any trauma, and she can't even remember the last time she worked when someone was intubated in the ED.

Now, obviously this is suboptimal. However, I'm curious to hear people's thoughts on just how suboptimal? One of my attendings at my home program trained in the military where his training was also pretty low acuity, but he said that after a couple years working in a high acuity urban ED he thought he had totally caught up. I mean, if you meet the RRC's numbers on intubations/central lines you should be fine, right?

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[edgesofsanity]

No one has ever completed residency wishing they had seen fewer critical cases.

 

[Arcan57]

Is that the only shop they train at? Are there extensive and realistic sim courses? The RRC requirements are ok, but if you're getting most of your procedures out of context of the ED then that's a problem. Intubating 50 ASA 1, Mallampati I/II patients on an anesthesia rotation isn't going to make you proficient at intubating in ED conditions. If the only time you're throwing central lines in is during ICU months when they're urgent but not emergent and you have experienced nurses to set everything up, you're probably going to be slower to pull the trigger on putting them in the ED on the patient that's getting shocky but isn't actively crashing. With that being said, it's unlikely the RRC would credential a program that had "urgent care" level of acuity.

 

[dotcb]

If you have another training option, I'd choose the other option.

 

[Rendar5]

My sick and dying patients were a blessing to me in my training as a resident. YOu don't need an ER where everyone's dying, honestly, but youneed at least some trauma training, even if it's just blunt trauma for the most part. And you need emergent intubations and central lines because those are not things you want to really be learning after you graduate. I mean I work at a not-so-acute community ED now, but I had 5 tubes this week after having 1 tube a month. 4/5 of them were difficult ones that I only got without too much difficulty because I have enough experience from residency. And I know for a fact that I would've needed multiple attempts or an attending to help me with back in residency. So even if you end up working a low acuity place, you will have weeks where you get tons of emergencies. Make sure that you get enough training on procedures and managing patients circling the drain. That said, I doubt that program can really be credentialed and not provide enough critical care and critical procedure training. Most of the junky programs I know of are the ones where you end up with malignant attendings or horrible ancillary services, or work you nonstop. Not ones that don't provide appropriate training.

 

[SoCuteMD]

I forget who said it to me and at what point it was said, but I was once told that you want your worst day as a physician to be as a resident, not as an attending. I'm not sure what the truth is about the program you mention, but if it really is consistent with your impression I would be very wary.

 

[Apollyon]

I am not bagging on DOs, in ANY way, but is this program a DO EM residency? It seems like some of the DO residencies are much more like the "wild west". Likewise, it seems that, whenever people in other specialties have some weird deal in residency (like the guy who would be called out of his residency rotations to be the "procedure guy" in the ED, which did not have an EM program, and ended up in numbers trouble due to this), it is in a DO residency where the AOA seems to be running a bit (or a lot) more "fast and loose" than the ACGME.

Again, not bagging on DOs - at my new job, it is about 1/3 DO. It's all good.

 

[ihearttriangles]

I am not bagging on DOs, in ANY way, but is this program a DO EM residency? It seems like some of the DO residencies are much more like the "wild west". Likewise, it seems that, whenever people in other specialties have some weird deal in residency (like the guy who would be called out of his residency rotations to be the "procedure guy" in the ED, which did not have an EM program, and ended up in numbers trouble due to this), it is in a DO residency where the AOA seems to be running a bit (or a lot) more "fast and loose" than the ACGME.

Again, not bagging on DOs - at my new job, it is about 1/3 DO. It's all good.

Nope. I would say more to explain why the program might be low acuity but I don't want to "call it out." And thanks to everyone else for the helpful comments. I pretty much knew people were gonna say what you all are saying but was hoping against reason maybe someone would have a different opinion.

 

[joeDO2]

take a look at the affiliated sites and out rotations. no accredited place is going to let you go without trauma. the things they don't have at the home institution are most likely covered at outside places.

 

[The White Coat Investor]

I think high acuity is really important. You can learn how to take care of low acuity folks without an attending looking over your shoulder. This is my biggest criticism of military training programs (which I have taught in.)

 

[tsbqb]

I am in the same position. There is one program I really like because it has great people and for its location but the acuity seems lower than a few other places I am considering.

That is my problem with some allopathic programs in smaller towns and in Manhattan. It just seems like the acuity is far less than what it is in other places.

Everyone I have talked to says that every program offers great training and that it is up to the individual to make the most of it. I ahve been told that just because you train at a place that supposedly has higher acuity it doesnt mean you will ultimately be a better doctor.

Tough decision though.

 

[Rendar5]

I am in the same position. There is one program I really like because it has great people and for its location but the acuity seems lower than a few other places I am considering.

That is my problem with some allopathic programs in smaller towns and in Manhattan. It just seems like the acuity is far less than what it is in other places.

Everyone I have talked to says that every program offers great training and that it is up to the individual to make the most of it. I ahve been told that just because you train at a place that supposedly has higher acuity it doesnt mean you will ultimately be a better doctor.

Tough decision though.

you don't need high acuity for good training. you just need to avoid truly low acuity.

 

[EM2BE]

I am at a program most would consider low acuity. We see many without big issues. Some days are definitely worse than others (0 level 1's one day, had 4 level 1's the next day). We go to other hospitals for different experience. It's amazing to see what differences exist. I found we get many more cardiac arrests than the higher acuity place. We manage much more prior to transferring a pt than we would at the other place. We get many walk-in traumas (a few GSWs and stab wounds, but mostly blunt). We get trauma experience elsewhere as well. Definitely less sickle cell and transplant patients, but they still come in. We get pediatrics combined in our ED, it's separate in the other. If you are seriously considering any of these programs you mention, just figure out if the out rotations complement the situation. I feel we get what we need, but I'm not stuck in that environment all the time.

 

[gman33]

Trauma is pretty overrated in my mind. Especially if you are at a trauma center.
Trauma at a community hospital with no real backup, that's a whole other story.

Patient populations are going to vary and present you with different problem sets.
It is nice if you can go to a place that trains at multiple varying sites.

Seeing sick patients is very important.
I don't think anyone will argue that point.

It is also important to see patients that aren't sick.
Most people who come to the ER aren't really sick, so you need to be able to identify who doesn't need an extensive workup.
If you don't, your ER will turn into a massive cluster, and people will hate working with you.

Places that are known for high acuity are usually intercity programs with violence and people who have so many problems they are near dead when they come in.
These same places also have many patient with no other healthcare access. So you will get tons of people coming in who have no emergent issue.
In the end, it probably averages out.