What to Look for in an Emergency Medicine Residency

Lee W. Shockley, MD, FACEP

What makes a good emergency medicine residency program?

The Residency Review Committee (RRC) for Emergency Medicine carefully interprets all EM program requirements and conducts  thorough site surveys of every EM residency.  Because of this process, it is essentially impossible to find a "bad" emergency medicine residency in this country.  Finding a good emergency medicine residency involves determining which program is the best "fit" for your own personality and selecting the program that best serves your needs.  The following information contains my opinions about what every applicant should consider when evaluating emergency medicine residencies and some delicate questions to ask during interviews and visits.  In addition to my views, you should consider the opinions of other respected experts in emergency medical education.

What really makes a really good emergency medicine residency program?

There are many key elements outlined by the Accreditation Council for Graduate Medical Education (ACGME), but you can break them down into these major areas:

1. Critical mass of patients and pathology
2. Critical mass of emergency medicine residents
3. Critical mass of qualified emergency medicine attending staff
4. Pre-hospital and ICU rotations
5. Commitment to academics
6. Commitment to resident wellness

I. Patients and Pathology

It is essential that the base hospital ED has at least 30,000 annual visits with a minimum of 3% (1,000) critical patients per year. Critical patients are those who are either admitted to the ICU or who go from the emergency department to the operating room.  At Denver Health Medical Center we have about 55,000 annual visits in our emergency department. During day-time hours, a pediatric urgent care center (PUCC) and an adult walk-in clinic (WIC) filter off a large number of low acuity patients raising the average number of critical patients treated in the ED.  At Denver Health Medical Center approximately 12% of our admissions are considered critical patients.  If the census from the WIC, the PUCC and psychiatric emergency service were considered, we would have an annual census around 100,000.

It is also essential to see a full range of pathology.  Emergency medicine residents should see all types and all ages of patients You don't want to miss anything. For example, you do not want to have separate surgical and medical emergency departments with varying coverage by emergency medicine residents.  A trauma experience must be included in the curriculum. Denver Health Medical Center is the Level One Trauma Center for the city and county of Denver. We also have a special commitment to pediatric trauma as recognized by the American College of Surgeons. 

General pediatrics should also be included in the curriculum.  The RRC requires a minimum of four months or the equivalent. By "equivalent" they mean that the program can calculate the pediatric experience based on their census. For example, if you are working in an emergency department for four weeks and the census is 25% pediatrics. You could be credited for one week of general pediatrics.

II. Critical Mass of Residents

The requirement is for at least six residents per year and at least 18 residents total in the program. The Denver Health Medical Center Residency in Emergency Medicine was recently accredited for fourteen residents per year for a total of 56 residents in the program.  Having the minimum number of residents is important for maintaining an identity.  If a base hospital functions without EM residents for large portions of time, they get used to your absence.  When you are there, you may not be given the sort of responsibility you really need to learn effectively. The program must have enough EM residents to have a significant presence in their own Emergency Department and to be readily distinguished from residents in other specialties.

III. Critical Mass of Qualified Emergency Medicine Attending Staff

The requirement is for at least six full time teaching attendings.  At Denver Health We have twelve full time attendings and twelve additional Emergency Medicine Faculty at University Hospital. Seven additional core teaching faculty are located at the other two hospitals participating in our program.

Ideally, faculty should be trained in emergency medicine.  However, emergency medicine is one of the newest medical specialties. If a physician came out of training 20 or 30 years ago, they may not have had the opportunity for Emergency Medicine Residency Training.  If a faculty member trained 10, 15, or 20 years ago, you could make the case that they could be trained in some other specialty, such as internal medicine, surgery or family medicine. However, if anyone in the faculty completed residency  in the last 10 or 15 years, they really should be trained in Emergency Medicine. All of the faculty at Denver Health Medical Center are residency trained in emergency medicine.

Regardless of what they trained in, even if they trained 30 years ago, all faculty should be board certified by either the American Board of Emergency Medicine or the American Board of Osteopathic Emergency Medicine. They are the recognized board certification standard in this country. The process of becoming board certified takes some time. For example, if you graduated from our residency program this summer, you would be eligible to take the written exam by the American Board of Emergency Medicine this fall. If you took it this fall and passed it, then you would be invited to take the oral exam either this coming spring or the following fall. If you pass the oral board, then you become board certified. It usually takes at least a year or a year and a half to become board certified. At the Denver Health Medical Center, board certification is required within three years of joining our faculty.

The Program Requirements for Emergency Medicine require an in-house on-duty Emergency Medicine attending. We are one of the few specialties that have an in-house attending requirement. The emergency medicine attending must be awake and available in the Emergency Department 24 hours a day for your supervision and instruction. At Denver Health Medical Center, we realized this a long time ago (about ten years before it was a formal requirement); we have had 24 hour coverage in our emergency department since 1977.

IV. Pre-Hospital and ICU Rotations

You need to have some pre-hospital and ICU rotations. The ICU time can be in a Surgery ICU, a Medicine ICU, a Coronary Care Unit or on a Critical Care Service.

You should have both an ongoing pre-hospital experience as well as a concentrated pre-hospital experience. The ongoing experience needs some time providing medical control over radio telephone for paramedics and EMTs. The EM Residents should participate in pre-hospital teaching conferences. They should be involved in paramedic and EMT training and have opportunities to provide medical care at special events and mass gatherings.  Residents should have a concentrated pre-hospital experience.  Ideally,  this should include field exposure so that you can really know what it is like being a paramedic in the pre-hospital EMS system.

V. Commitment to Academics

The RRC has a requirement for "scholarly activity". We interpret that to mean that each resident must produce something of publishable quality before finishing the residency.  It makes no sense at all to write a paper that is of publishable quality and keep it at home in a desk drawer. It ought to get published and make you famous. Most people who finish a residency program will have at least one or two publications under their belt by the time they are finished.  It doesn't have to be a research project. If you want it to be research that is fabulous. We would be very supportive of that and very pleased for you to do primary research. But there are people who are not researchers who would rather fulfill this scholarly activity requirement by writing a book chapter, a case report, a case series, or by writing a review of a particular topic.

If you are interested in research, select a program in which resident research is supported and where faculty are actively engaged in research. One way of figuring this out is to take a look at a faculty interests book (ask to see one). It should list the types of research projects that the faculty are doing and their selected publications. Look and see what the attending staff are doing and see how active they are in publishing. Look especially to see if there are dual authorship papers: are there papers that have both the faculty member as well as the resident on the same paper? This usually indicates how involved the staff are in the academics of the residency.

Ideally, the curriculum should include elective time.  You really don't want to have to take care of patients all night long and then try to do your research project during the day when you should be asleep. It is important to have protected time for projects. We offer up to four weeks of protected research time and up to six weeks of standard elective time; many residents use a portion of the elective time to concentrate on a project.

Lastly, the program must have formal didactic teaching conferences. The RRC requires a minimum average of five hours of didactics every week.  At Denver Health, all of our residents have protected time to attend a weekly teaching conference.  Every Wednesday, all residents, including those rotating on non EM services, are freed from clinical responsibilities to attend teaching conferences.  The weekly conferences includes a morbidity and mortality conference, attending and resident lectures, EM board review / simulation, and guest lectures by visiting renowned EM faculty or experts from other relevant specialties.  

VI. Resident Wellness

The EM Residency Program must pay attention to a reasonable work schedule for residents. The RRC caps the number of hours residents can work per week and requires a minimum amount of time off.  Scheduled time in the emergency department is limited to 60 hours per week.  A period off equal to the length of a shift worked is required between two shifts and you must have one day off every seven days.

The EM Residents should enjoy working with a supportive staff and supportive residents. If it is going to be a difficult place for you to get along with people, it is also going to be a very difficult place to practice emergency medicine effectively and a difficult place in which to learn.

The EM Residents should have some input into the the residency program either through a residency advisory committee (RAC) or through retreats. The Residents should have a diversity of opportunities and a diversity of experiences; you do not want to be doing the same thing day in and day out for your entire residency program.

You also should enjoy the environment in which you live. The availability of recreational activities will go a long way to helping you be a happy and productive Emergency Medicine Resident.

Some Delicate Questions to Ask:

"Who Directs the Resuscitations?"

Some questions that you are going to have to ask are: "What is the functional status of this emergency department?" and "Are they their own department?"  One way to find that out is to ask, "Who directs the resuscitation in the emergency department?" For example, is anesthesia called to intubate patients? If your patient needs to have their airway managed, do you have to call someone else out of their familiar environment to the emergency department, an environment in which they may be uncomfortable.  I feel very strongly that emergency physicians are the experts at handling the emergency airway. It is one of the most important things we do in our practice and we need to be skilled at it. This is our emergency department; we know where everything is kept; we know the people we are working with; we do not have to leave our environment to go someplace else to manage the airway. Emergency Physicians also have an advantage of being able to oversee the entire resuscitation. Not only are we taking care of the airway, but we are also taking care of all of the other critical problems in that same patient.

"What is the Role of the Emergency Medicine Residents in Trauma Care?"

Is the role to pick up the telephone, summon the trauma team, and step out of the way, or is it actually to have a very active role on the trauma team?  It is important to ask; Who directs the trauma resuscitations? Who directs the pediatric resuscitations? Who performs the technical procedures? If it is your patient in your department and you decide that they need to have a central line or a chest tube, do you have to call someone else to do that or is that going to be in your scope of practice? Our EM Residents share the role of Trauma Captain with the Surgical Residents and perform almost all of the technical procedures.

"Is there Graded Responsibility?"

You would like to see some graded resident responsibility in an emergency medicine program, taking on more responsibility as you progress through the residency. One way of evaluating this is to look at the schedule. See if there is the simultaneous presence of  senior emergency medicine residents and junior emergency residents on the schedule.  If they are there, see what their specific roles and responsibilities are.  At the Denver Health Medical Center, our senior residents don't practice anything at all like our junior residents. They have very different roles and responsibilities.

"What is the status of the program's ACGME endorsement?"

Programs may be granted the following endorsements by the RRC?

1. Provisional Endorsement. This is granted to any new program for a period of three or four years. If a program is on continued provisional endorsement for greater than four years, it would be prudent to ask to why the program has not progressed from provisional to full endorsement.

2. Full Endorsement. This may be granted after a program has been provisionally endorsed for three or four years and resurveyed.  Full endorsement may be granted for three to five years, with five years as the maximum. The Denver Health Medical Center Residency in Emergency Medicine received a continued five-year full endorsement in 1999 and in 2004.

3. Probation. If a program is placed on probationary status, this indicates that there are multiple significant deficiencies in the training program which must be remedied in one or two years. If the program does not correct these deficiencies, the accreditation status of the program will likely be withdrawn.

Training Formats:

As you are probably aware there are different residency training formats in emergency medicine. There must be a minimum of 36 months in the curriculum. The majority of the programs are EM-1, 2 and 3, right out of medical school. About a quarter of the programs have a fourth year, either in a 48 month format EM-1 through 4, right out of medical school, or an internship (EM-1) year in a another program and then joining the EM Residency in the EM-2 year for 36 months (EM-2, 3 and 4.)

There are currently 136 ACGME endorsed programs in emergency medicine in the United States. About three-quarters of those, who train about 60% of the residents, are EM-1, 2, 3 formatted programs. About a quarter of the programs, training about 40% of the residents, have a fourth year, either in a EM-2 through 4 program or a EM-1 through 4 program. 

You need to ask yourself if a fourth year is valuable to you. Just like anything else there are advantages and disadvantages.

Advantages of a Fourth Year:

One of the advantages is that there is an additional year of administrative and clinical training. You are probably better trained for having been at it longer. It will probably also give you the best competitive edge in the job market. If I were looking at two similar resumes from two residents applying for a faculty position, and they are exactly the same except that one applicant came out of a four year program and one came out of a three year program, the fourth year person would probably get that advantage, simply because they have had more training.  A fourth year will also give you immediate preparation for an academic position. For example, we would not hire someone on our faculty who came right out of a three year residency program. The reason for that is that they would be four years out of a medical school and they would be supervising people who are four years out of medical school who may actually be in a stronger residency program than the applicant came from. It would not be fair. So if you came out of a three year residency program and you wanted to take a faculty position with us, it would mean that you would have to go out and work someplace for a year or two or you would have to do a fellowship before you would be acceptable to this faculty. A four year program really keeps all of the options open.

Disadvantages of a Fourth Year:

What are the disadvantages? If the fourth year is so great, why aren't all of the EM residency programs structured that way? One of the disadvantages of the EM-2 through 4 is that medical student applicants have to send out two applications: they have to apply for an internship and apply for a residency program. It means more of your time completing the applications. It also means more of your time in the travel and interviews. The other thing to keep in mind is what people call "the $100,000 mistake". That is an additional year at a resident salary as opposed to a year as an attending physician. Whether or not that is a mistake or whether not that is an investment depends entirely upon the fourth year curriculum. If the fourth year curriculum has things in it that are unique and valuable, that you couldn't receive any other time in the residency or potentially any other time in your career, then that is something that is an investment that you really ought to look at. It will pay off for the rest of your career. On the other hand, if the fourth year curriculum looks exactly the same as the third year curriculum, then it is a $100,000 mistake. You are wasting your time and you may as well go out and make that additional $100,000 for that year.

Some More Delicate Questions to Ask:

These are questions you want to ask of anybody that you can: the emergency residents, the faculty, house staff from other services, the ED nurses and clerks, the housekeepers, everybody that you can think of.

What is the quality of the other house staff in this hospital?

Ideally, you don't want to be in a residency program where the EM residents are head and shoulders above the rest of the house staff or head and shoulders below the rest of the house staff. If the EM residency is by far the highest quality residency program in that hospital, the residents may find that when they are on an off service rotation, they are doing more teaching to the off service residents rather than learning from them. You really want to have an excellent learning experience everywhere that you go. You want to have high quality people to work with and to learn from. Similarly, you don't want to be thought of as being the poorest quality residents in a hospital.  You don't want to go to another service and not be given the responsibility and respect that you really need in order to learn maximally. Ideally, what you would like to have is an EM residency program where all of the house staff in all of the residency programs are first class. We believe that we have this at the Denver Health Medical Center.

What are the relations like with the other services?

Are there turf battles going on? Is this a place where there is some professional respect between colleagues at both the attending and resident levels?  You will find that our relations with all the services at all the institutions involved in this program are superior.

What is a typical day like in the emergency department?

If anybody can tell you what that typical day is ask them, "Why is there a typical day?" Emergency medicine, by its very nature, should be diverse. There shouldn't be a typical day. It should be different and exciting every time you come to work.

What are the relations like between the attendings and the resident staff?

Do they get along together? Do they have a good time together? Do they hate each other? Are these the kinds of people that you are going to enjoy working with for three years? What is the workload like? Is it so heavy that at the end of the day when you get home you are exhausted and you couldn't think of opening a book. Therefore you are never going to learn any alternate ways of doing anything other than what you have just been shown. So you will continue to make the same mistake time after time. Or is the workload so light, that you are never going to see patients with exotic diseases and you are going to have to learn about all of those things from a book? Or is there a very nice mix? Are you going to have a reasonable workload with some interesting clinical material but also enough time to learn from them?

What is the residency's policy on moonlighting or the resident's experience with moonlighting?

Ask the residents if they moonlight and why they moonlight? Do they say, "we all feel that we must moonlight because the cost of living is so high and our salary is so low that we can't make the mortgage payment or we can't make the rent?" Or do they say, "We moonlight because every place in the residency program someone is looking over our shoulders all the time and we never get any opportunity to practice emergency medicine with any kind of autonomy?" Or do they moonlight because its fun. They enjoy it, it gives them an opportunity to explore some other practice options and make a little bit of extra money on the side.  Some of our EM Residents moonlight and we believe that it is for the latter reason.

Who has admitting privileges?

If you decide a patient in the Emergency Department needs to be admitted, what happens then? Do you call someone from an in-patient service who comes to the emergency department, looks at that patient, and maybe agrees or disagrees with your assessment. Residents are on an in-patient care team may be junior to you in terms of years of training and is also not trained in emergency medicine.  They may lack an appreciation for the role of emergency medicine.  At the Denver Health Medical Center, we have admitting privileges to any service in the hospital. If we determine a patient needs to be admitted, they will be admitted.

How many hours a week does your program director work?

A program director should work at least two shifts a week in the emergency department. This exposure is crucial to have an understanding of what is going on in the residency.Our program director works on average 20 clinical hours a week (about two and a half shifts a week). They have the same portion of nights, weekends, holidays, and special events as everybody else on our staff. You'll have just as much chance of seeing our program director in the Emergency Department at 2:00 am on a Saturday night or on a holiday as anybody else on our faculty.

How many hours a week does the emergency department director work in the emergency department?

There are many academic emergency departments where this is a non-clinical, completely administrative position. The director rarely or never works in the emergency department. How can you really administer an emergency department if you don't even know where the thing is.? A director should work one and a half or two shifts a week. Vince Markovchick, our director, works two shifts a week on average and has the same number of weekends, holidays and special events as the rest of the faculty.

Some of the habits of some highly successful emergency medicine residents and emergency medicine applicants:

If you haven't figured it out so far, you are going to figure this out during your interviews: People who apply to emergency medicine, and residents in emergency medicine are not like people applying in other specialties. They are the people that you are going to gravitate towards in hospital cafeterias, in hotel lobbies, and in the terminals at the airports while you travel to your interviews. These are the folks you want to sit next to. They are a lot of fun; these are just attractive people. They are interested, interesting; they are high energy. They like to work hard; they like to play hard. They have interests outside of medicine. They are very committed and want to make the most out of their emergency medicine residency program. These are people who know, "I am only going to do this once, I really don't want to miss anything." So they subscribe to that philosophy that, "Whatever isn't prohibited is mandatory." They want to taste everything that they can; they don't want to leave the buffet of EM Residency Training without a full plate.

In general, you may not find that type of high energy person applying to residencies in other specialties.  It's self-selection and it's going to assure the success of our specialty in the future.