r/emergencymedicine • u/rasberrycordial • 3d ago
Advice Which EM residencies are known for the most hands-on training/procedural autonomy?
MS3/4 here trying to build my EM program list and I’ve realized trauma designation alone probably doesn’t tell the full story about resident experience.
I’m much more interested in programs where EM residents are heavily involved in:
- running traumas
- intubations
- chest tubes/central lines
- fracture/dislocation reductions
- procedures in general
- actual autonomy in the ED
Basically looking for programs where EM residents are truly “hands on” and not standing in the corner while surgery/anesthesia/ortho does everything.
Would especially love to hear about:
- busy community programs
- unopposed programs
- Level 2s that function like Level 1s
- programs with strong county/community exposure
- places where residents graduate feeling very comfortable independently managing sick patients
Any specific programs/systems people think are known for excellent procedural training and autonomy?
Also interested in hearing the opposite - places where EM tends to get sidelined in trauma/procedures.
Thanks!
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u/TheOtherPhilFry 3d ago
Sinai Grace in Detroit is a level 2 but historically the busiest in the city. EM runs traumas and has first right over procedures on trauma patients with a very collegial relationship with surgery. Also EM does airway. No fellows in MICU/SICU so there is a lot of autonomy there as well. Ortho likes to respond to pages somewhere between six hours to two days from when they are paged.
If you can do it there, you can do it anywhere.
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u/but-I-play-one-on-TV ED Attending 3d ago
Can I go back and do my ortho residency there? Sounds pretty chill
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u/TheOtherPhilFry 3d ago
Only if you want to be a PA. Residents largely covered the mothership downtown.
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u/LifeTakesThingsBack 3d ago
I was going to say the same thing. As I was reading his post I was thinking he was describing Sinai Grace. I’m not sure what it is like now, but back in the day it was somewhat brutal but excellent training. I have no regrets.
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u/TheOtherPhilFry 3d ago
My time there was good except for COVID happened during my residency and everyone died.
https://www.cnn.com/2020/04/13/health/detroit-hospital-bodies-coronavirus-trnd/index.html
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u/kilk0009 3d ago edited 2d ago
The last things have changed significantly in the past decade. Sinai Grace was an amazing place to train as an EM resident.
Edit. *"Unless" things have changed...
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u/coastalhiker ED Attending 3d ago
Had a colleague that trained there, most unflappable doc I have worked with and our department is a melting pot of people from the top residencies in the country.
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u/TheOtherPhilFry 3d ago
Whenever someone at my current ERs complains about dysfunction I tell them it is quaint and adorable compared to SGH.
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u/sgw97 ED Resident 3d ago
Sinai grace barely sees bread and butter medical patients though
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u/TheOtherPhilFry 3d ago
The thing you learn about bread and butter is it doesn't take much to chew it.
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u/Dependent_Grocery572 8h ago
med student here doing her rotations at Sinai grace….made me wanna do EM haha
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u/reachfell 3d ago
The residency I’m about to finish in NYC is exactly this. Level 2 trauma that acts like level 1, stroke/stemi center, and residents basically run the whole hospital. ED residents get all the procedures in the ED. We have an incredibly sick population.
It’s not worth the downsides. I would never do it again.
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u/rasberrycordial 3d ago
HELP 😭😭😭 I have heard a lot of the NY programs are like this but then they're super malignant as well so I don't think it'd be worth it :/
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u/reachfell 3d ago
I made sure to never let my mom or wife see my ED because I knew they’d never sleep as well again. It is not safe for patients or staff. There is no rule of law. NYPD is complicit, dumping violent people who were threatening others with weapons or fire into our ED then leaving as a matter of routine. It‘s not worth it.
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u/LunarSoul ED Attending (not that ED) 3d ago
Definitely not worth it now. NY is a shit hole. Also very litiginous. I've known some of my resident colleagues who were sued etc. A lot of non-physician tasks due to union labor and stuff.
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u/Suitable_Status_5212 3d ago
I do second Corpus Christi EM. I rotated there as a student and in one month helped with a lateral canthotomy, a few chest tubes, intubations and a thoracotomy. Probably an abnormal month, but there is very little competition, the only other residents are FM. They have enough resources to have some specialty assistance, still. And a pretty sick population in general. I did not do residency there but know people who have who had good experiences.
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u/skillfulskeleton 2d ago
Third vote for Corpus. I did do my residency there and happy to answer any questions.
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u/willsnowboard4food ED Attending 3d ago
Look into Cooper in Camden NJ. You get all the life style benefits of a Philly program and all the learning/experience of working in Camden.
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u/kechupmed ED Attending 3d ago
UAB. Level 1 trauma. Manage 9 bed pod as an intern by yourself with attending oversight. Split days with trauma surgery even days you run the trauma, odd days you do all procedures. I came out of residency with over 200 intubations, 150 CVLs, 50 chest tubes
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u/dasnotpizza 3d ago
You want to find a standalone place that’s a hybrid community/academic program. For example, Christiana is a level one trauma center that does not have an ortho residency, so you’ll have plenty of experience managing fractures in a way that you wouldn’t get a traditional academic center with a bunch of residencies. Tons of blunt trauma and penetrating trauma, along with complicated medically, sick people. The residents there get a lot more clinical experience than the residencies at more traditional academic places since there is less competition as compared to a city, where there’s multiple hospitals.
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u/rasberrycordial 3d ago
This is the one is Delaware, correct?
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u/dasnotpizza 3d ago
Yes, and when you train at a standalone facility where there isn’t a bunch of competition, you end up seeing a lot more than being in an urban center. That was something that surprised me. You think it would be a hospital in a major city, but the thing is that there is a ton of other hospitals in cities, so it dilutes the catchment.
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u/but-I-play-one-on-TV ED Attending 3d ago
I did residency in NYC and can 100% attest to this phenomenon
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u/EM_Doc_18 ED Attending 3d ago
Will give a nod to UAMS in Little Rock. Traditional level 1, but the consultant residents want you to do as much as possible before calling them. EM runs traumas and does chest tubes on the right, surgery does them on the left. After a few months, surgery could not care less as they have other things they want to be doing and OR time they want to get back to. Ortho does not want to do the reductions and honestly don't want to be called until you've tried once (EM is better at reductions than most of Ortho, the senior ortho residents MIGHT be better). There is a community rotation at a nearby hospital where you will do EVERYTHING. PGY-2 and 3 are "upper levels" and work the same shift, no difference in responsibility.
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u/Murrrrdawg ED Attending 3d ago
Carolina’s Medical Center in Charlotte
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u/fitnarp 3d ago
Could you speak on this program a little more please? I haven't considered Charlotte at all.
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u/Murrrrdawg ED Attending 3d ago
I did my residency there so I’ll communicate my bias freely.
I left with 120+ intubations, 50+ central lines, 40 deliveries and what felt like a million chest tubes.
We do share procedures with trauma in the ED but never airways. One of our residents is on trauma service and another upper level on STICU at all times so even when sharing with trauma, often times it’s still us.
We are the preferred residents for procedures on all medical rotations.
Happy to answer any questions you have on the program. I enjoyed my time there immensely and highly recommend it.
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u/but-I-play-one-on-TV ED Attending 3d ago
Carolinas has a stellar national reputation as well. I was regionally locked to the NE for residency but there and Denver were two programs I really wish I could have applied to.
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u/hottmfh 3d ago
Lehigh valley Allentown pa. Finished my procedure requirements before mid way pgy2 (except for cricothyrotomy but I’m close!). We get plenty of trauma and an obscene amount of various ICU (tnicu, unopposed micu, cicu, picu) that we get a ton of procedures there too. All off services rotations are in house too, so no change in travel time.
In the ED itself we do all procedures unless we physically can’t, and even then we are doing the sedation. I’ve never had an ortho procedure even talked about ortho coming down unless it had to go to the OR. Intubation is day 1 intern priority, I’ve gotten phone calls while on off service rotations in the hospital (ultrasound etc) by seniors to do intubations. While off service they just show up to bedside as backup.
At our level 2 we run the traumas, at our level 1 juniors are the mic and seniors are head of bed, and we have an awesome relationship with our trauma surgery teams so we get mostly any procedures that show up in the trauma. I have so many central lines I lost count. chest tubes are ebbs and flows on what shows up but I’m comfortably done with my requirement as a pgy 2, and some of my co 2s have lapped me, either way you get a ton. As for autonomy in the ED, it’s us and only us first. Consults are for when we are out of our depth, for advice, or for admitting the patient. A lot of the consult services first point of contact are staffed by EM residents anyways so you’re giving the procedures to your friends (tnicu, trauma, picu, micu) in those cases.
The hospital network is wide so between our two trauma centers and community site, all within 10 mins of each other at most, you get exposure to everything. We are extremely comfortable with sick patients, and you get that confidence early. Really strong teaching cultures driven by both admin and residents. You get community exposure to cases and procedures while still getting academic resources and pathology. Not to mentioned beautiful new trauma bays in each site.
If you’re looking for hands on training, Lehigh excels at it. We are a four year program and Allentown has plenty to do but it’s not a true city program, so not for everyone but definitely hit the benchmarks you posted here. I’m a rising pgy 3 here, so reach out if you have any questions I’d love to answer!
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u/fitnarp 3d ago
Following. Why is this post getting downvoted?
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u/MrPBH ED Attending 3d ago
Because the people that ask these questions don't understand that what they're asking for is highly undesirable. Many people think that they want to do a lot of procedures, but few feel that way after intern year.
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u/dasnotpizza 3d ago
Yeah, but that’s why it’s great to train in a program like that because you get a bunch of experience versus being an attending in a community site where you might not have done a lot of reductions or have only done a handful of chest tubes and now you’re on your own, trying to figure it out. Sure, as an attending, I’m not that interested in doing procedures or in traumas the way that I was as a resident, but I loved the fact that my residency was very procedurally heavy, and I was very comfortable with almost everything by the time I graduated.
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u/traumabynature 3d ago
Exactly, this is the type of place most people don’t want to work at as an attending lol.
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u/rasberrycordial 3d ago
Oh, I did not think of it that way. Could you elaborate a little?
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u/MrPBH ED Attending 3d ago
Most emergency doctor lose their interest in procedures after residency (honestly, a lot lose that interest in residency).
Imagine that you are busy managing 8 active patients and there are 20 more in the lobby. You haven't finished a single note all shift and just got out of a room where you spent an hour coding a nursing home resident. Now you get a phone call that the guy who fell off a ladder has a hemopneumothorax and you need to place a chest tube.
The patient is in the hallway and you have to negotiate with the charge nurse to get them a room. After several back and forths, they're in the room. You now need to chaperone the nurses and direct them on how to set up everything for the procedure. They still forget to plug in a new suction canister. The new nurse doesn't know how to set up the PleurE-Vac so you have to walk them through it. The tech brings you a clamshell thoracostomy set instead of a tube thoracostomy set, so you have to wait for them to bring that back. "Also we don't have that size tube, what do you want instead?"
Finally, the patient is ready and you have everything. Oh wait, where's the lidocaine? Also can you give them 2 mg of Versed because they're wigging out. Great time to start. Anesthetize, cut, spread, sweep, tube. There's no shoe protectors, so when the forceps went in and blood gushes out, that blood drips from your gown onto your sneakers. The nurse fumbles with the suction tubing and hands you the wrong end. You have to explain again how it works and which end plugs into which.
You ask for xray as you're tying the tube down. No one has the BIG tegaderm, so you have to tape gauze over it. Done. But where's xray? "Oh, they said they need an order." You now ask for the nurse to place a verbal order and call xray back.
You get back to your desk after reviewing the portable image. Twelve new patients have checked in and every old patient has been replaced with new ones in your pod. You curse under your breath as you start writing down room numbers on your to do list.
Does that make sense? A procedure that takes 30 minutes (in theory) can ruin your flow and put you in a hole that will ruin the rest of your shift.
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u/rasberrycordial 3d ago
Yeah, I see what you're saying. How badly does the harsh environment continue after residency?
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u/Mediocre_Ad_6020 3d ago
This really depends on where you work, but even at nice places, procedures take time and patient volumes are going up
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u/fitnarp 3d ago
I really appreciate your perspective! I was really interested in this post bc I plan on practicing in a rural ER and figure more procedural experience is going to benefit me.
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u/bones30254 2d ago
Consider the EM residency at Christiana Hospital in Newark Delaware- a level one center not in an urban setting- you will see a lot and do a lot
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u/G00bernaculum ED/EMS attending 3d ago
I think these questions are always impossible to truly answer. Most of us have only gone to one program.
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u/rasberrycordial 3d ago
Yeah of course that's true. But I guess I assumed that the people who resonated with the post + their program might give their input (which they are!)
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u/rasberrycordial 3d ago
Yeah idk either 😭😭😭😞
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u/jeremyvoros ED Attending 3d ago
That’s how Denver was for me. Plenty of procedures. As an intern I had more intubations and central lines than my ICU senior resident. By the time I was a senior resident most of the procedures were almost a chore I’d done so many.
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u/orchards_rest 3d ago
Charge resident system at LSU New Orleans gave a lot of autonomy, plenty of procedures, traumas. UMCNO is a level 1 with surgery and trauma programs so may not be entirely your bag, but you get a lot of rotations at outside community hospitals and rural sites as well, opportunities for moonlighting (at least while I was there years ago) give you a lot of experience on your own.
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u/droperiLOL 3d ago
Louisville pretty much fits the bill. Functions more as a county hospital with plenty of community exposure. Trauma only comes to Level 1s, which are called at your discretion. You do any and all procedures you want, except trauma does do some of the lines/ chest tubes once they are invited into room 9. As a PGY 2/3, you have more autonomy than you could ever hope for. I feel very confident in my training, and felt more supported (both on shift/ as a physician, as well as just as a human) than I could have ever imagined during my training.
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u/hopefulERdoc252 3d ago
Plug for UMMS Baystate - graduated here with >120 tubes, >70 lines and plenty of chest tubes. Part of many sick trauma resuses including thoracotomies however if they were cracking the chest we did the right sided ctube while surgery started on the left.
Got pretty much all of the HALO procedures (few TVP, cric, pericardio, lateral cantho). We had 4 pods, each pod had a pgy3, pgy2 and intern +/- off services. As a pgy3 you were team leader, ran resuses with your attending behind you, pgy2 did tubes, interns did lines/us so we had graduated responsibility. Going from that to a high volume high acuity community center with no residents - I felt very prepared for mostly everything and working as an EMS physician, the stuff I learned from residency very much has translated in the field
Leadership was supportive, attendings gave you a long leash as long as they trusted you as a pgy3. Only residents that opposed you were surgery in the bay but they had a pretty good setup for equality of procedures. No ortho residents or ophtho/Ent in house so you did all the cool procedures with that. Ortho would be in house (PAs) but if you showed initiative and asked to do reductions they would let you and teach you thru it which was helpful in the community. You also got community ed rotations and could moonlight at the community sites where it was pretty much you doing stuff with attending oversight.
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u/motoprincess ED Attending 2d ago
Detroit Receiving or Sinai Grace - both DMC programs. Both are solid and match your description. Excellent training + vibes
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u/hurricanepb34 2d ago
Hennepin County in Minneapolis is very strong procedurally and run all of their own trauma
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u/drinkwithme07 3d ago
BIDMC has a ton of community hospital time, where you are almost always the only resident and being pulled in to see basically all of the sick patients/do procedures. Should come out very confident & competent running resuscitations independently (and it's a 3 year program).
At the main campus they share trauma procedures with the surgical residents, but it works reasonably well, and airway is always EM unless we call anesthesia (vanishingly rare, except up in the ICU where the intensivists for some reason have fully given up the airway). Also rotate at a community ICU in PGY3 which is extremely procedure heavy.
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u/AbdominalSepsis178 EMT 2d ago
hcmc in minneapolis is omega strong and runs their own traumas. we are an urban safety net trauma 1, so it doesn’t hit all of the criteria you’ve given, but we’re still super strong and all of our residents end up hitting their procedural requirements by year 2
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u/Intelligent_Bet_5401 RN 2d ago
Vanderbilt would be my go to. I’ve been an ED RN 46 yrs. You’ll get a lot of procedural experience. You’ll also get pre hospital experience and get to work Poison control with the brightest physicians I’ve never worked with. In my travel experiences the last 8 yrs I have yet to run across anyone as well trained.
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u/GoodRecommendation95 2d ago
Buffalo was like this when I was there ‘16-‘19. Great program. Liked it there a lot. Plenty of autonomy and procedures
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u/traumabynature 3d ago
My advice go where you will thrive outside of residency and have a good support system. You will get more than enough reps at most solid EM residencies to be procedurally competent.
Traumas and codes are all an algorithm and start losing their shine after intern year. You start to realize how disruptive most of this stuff is to workflow pretty quickly into residency and having specialty backup is nice.
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u/Intelligent_Bet_5401 RN 2d ago
Wow, you obviously weren’t meant for this work. Yes, it all is an algorithm. But it’s important to pick the correct algorithm and modify to effect.
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u/OwnKnowledge628 2d ago
It seems more like the point is that following trauma and ACLS algorithms becomes less “new and exciting,” and you learn to appreciate the more “mundane” but mentally stimulating cases— things that don’t fit a neat flow chart but require more thought.
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u/Ok_Action_1590 1d ago
You definitely do not want a level 1 academic center because that will happen, places like Desert Regional Medical Center which is a level 1 trauma center but they do not have an ortho residency and trauma and EM swap days for procedures. You want places at least like that if you want trauma heavy, procedure heavy is any relatively high volume place where you don't have to compete, level 2s or less. I'm at a level 4 and I get a ton of procedures, and we did Trauma at a level 1, ICU we get so many procedures too.
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u/needdlesout 3d ago
I’m at a tertiary center with lots of resources, L1 trauma, community center. One of the busiest ED in the country, v sick patients. You can DM me for name, Ive had a great experience here
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u/EnvironmentalLet4269 ED Attending 3d ago
You're looking for community level II tertiary centers with assloads of resources but no surgical/anesthesia/cards GME programs.