We’re Failing Our Residents: Training ED Docs for the Real W… : Emergency Medicine News

February 2010 – Volume 32 – Issue 2 – p 5, 24, 25, 26

Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day. This community hospital ED will likely not be designated a Level I trauma center, and the practicing physician will have to make decisions on complicated patients without all of the resources and consultants available at a tertiary care medical center. He will have to make these decisions alone. Given that most graduating emergency medicine residents will practice in such a setting, we should ask ourselves is this the best we can do? Does the current training model best prepare the emergency medicine resident for the kind of practice he will enter

via We’re Failing Our Residents: Training ED Docs for the Real W… : Emergency Medicine News.

Nicely done.

I noticed this myself, first job out of residency.  I could do trauma in my sleep, but had a very steep learning curve at a place with high-end (and high-expectation) cardiology groups.

The reality that in ‘the real world’ there were no surgical consultations, they just wanted to know one thing: do I need to operate or not?  Also in the real world, going from a strong-hand department where the ED was regarded as the best residency with the best residents to being the new guy and the ED is the Repository of All Hospital Guilt, so no matter how thorough you were, the inpatient disaster was phrased so as to be something missed by the ER doc, and not the admitting team.

I did rotate (for one month, at the end of my residency) at a somewhat lower volume community ED, but there’s only so much to be learned while being a visitor for 18 shifts.

This doesn’t mean my trainers were lazy, or bad; it’s the reality that the hospital paying our salaries had expectations we’d be able to see the patients in that joint.

(This is, by the way, one of the better things about moonlighting as an EM resident; stretch yourself, find out what you don’t know while you still have time to learn.  We moonlit at a place about 45 minutes from our Big Center, so there was a safety net to catch us…)  Moonlighting is now Verboten, so there’s another door closed.

I’d like to see the residencies in EM move to decentralize from one place, and give a more rounded experience.  Not going to happen, but it would be nice.


  1. I know I am going to open a can of worms, but I want to make it clear that I do not intend to insult anyone or their training. Speaking as a physician who interacts with the ED extensively, I have found that most of the older physicians who did not train in ED residencies — because they didn’t exist — have a much greater “feel” for certain surgical problems. I think that this is because in their training, they saw patients through their hospitalization. Today’s ED residents would perhaps benefit from more time on the wards, perhaps serving some time with a hospitalist team and with a surgical team. This would allow the ED resident to see that the evaluation and care of patients is ongoing throughout their hospitalization, and perhaps be better at anticipating what the admitting physicians need from the ED evaluation.

    Just my 2 pennies. But again, maybe the older ED docs just have more experience.

  2. Unless EM residencies are extended to 4 years I just don’t see where the time is going to come from to teach all these additional skills.

    Look at it this way, would you rather have your newly graduated EM resident faced with task of learning patient satisfaction, consultant satisfaction, and reassurance of non crucially ill populations or figuring out how to put in a central line, chest tube, resuscitate a floridly septic patient, etc. on the job(rare though that might be)? The former skill set, while frequently frustrating to learn, nevertheless doesn’t involve life and death.

    Also I think the jobs taken by many residents straight out of residency just aren’t that great(a point made in the article about turnover of new grads). We all know that there’s a handful of nice “cush” hospitals that both pay well and are pleasurable to work at with good ED leadership. These places are well staffed and getting in requires a good resume and some networking. I think a lot of folks move on to greener pastures once they’re available.

    DocSurg – In some ways you’re probably right, though I could argue that some of my surgical colleagues might have benefited from a little more time in the ED!

  3. I agree…I work in a large hospital with every subspecialty available. However, our ER group has started providing coverage for some outlying smaller hospitals again, and we’re all loving it. You do practice a different kind of medicine when you are alone in the country.

    I would like to make a point with Aggravated DocSurg. The same shoe you are placing on ER programs should also be placed on recent surgical programs. EVERYBODY gets an abdominal CT in our ER, when a surgeon is consulted. While we try to discern who may or may not need one, the minute a surgeon is called, one is ordered. The clinical exam has fallen behind, in some cases, the radiological exam. And like you, not all the older surgeions do this, but the younger ones–hell yeah! Some of the surgeons don’t even carry stethoscopes anymore…

    Enjoy the day.

  4. It may be a poorly worded sentence on Dr. Welch’s part, but there is no way on God’s green earth that any emergency physician sees 200 patients a day. That would amount to 20-25 patients per hour.
    I split my time between low volume and high volume hospitals. I also find that at the low volume places, many primary care physicians and consultants have a low threshold for refusing patients and requesting that I transfer them. Trauma, possible strokes, new onset seizures, patients who need surgery but who have multiple comorbidities, HIV patients, dialysis patients – most get sent out. One doc doesn’t like accepting chest pain patients because “what am I going to do here if it’s an MI? We don’t have a cath lab.”
    I’ve found that working in a rural environment makes one a better ED physician at the cost of perhaps not keeping up with the most current cutting-edge medicine breakthroughs. Depends upon how you apply yourself.

  5. I have worked in both Level 1 Trauma centers and small community hospitals. One thing I find funny is when I have to retake ATLS, it’s always at a big trauma center and the guys teaching it
    ( residents mostly) have no clue about the lack of support these hospitals have. “Involve the surgeon right away in the care of this patient”- my reply? “Uh- we don’t have one” leaves them speechless. You see a LOT of trauma in the small rural hospitals, whether you have the capability to treat them or not. No luxury of “call in the Trauma Team”- it’s just you and two nurses. The EMS? Sometimes just a volunteer EMS unit that splints legs with cardboard. Yes, they need to rotate the residents into the “real” world.
    Two very different worlds indeed.

  6. I’m no expert, but I’ve had a chance to get involved in the GME aspects of the EM residency at my institution and this comes up alot. Part of the issue is findin precepting institutions that will take residents, and be anywhere in the area. One residency actually sends residents out of state for rural emergency medicine because they couldn’t find a hospital within an 8 hour drive that would accept residents at all.

  7. Hospitalist says:

    I work in a hospital that has no: neuro, GI, ENT. i know this and the ER knows this. Yet they call me to admit people for ERCPs and acute CVAs. Blows my mind.

  8. This is where medicine can learn from the education sector. Due to the fact, that only 50% of teachers remain in their field after 5 years, places of higher education are retooling their programs and adding year long externship/student teaching programs in both suburban/rural schools and inner city schools.
    Although I am not in medicine, I believe this same concept may work. Residents could spend one rotation or more in a county hospital and the remaining rotations in the suburban/urban counterpart. If it would make for better doctors, and give residents a wider arrange of experiences.