Recognizing Resident Turnover Red Flags in EM-IM Combined Programs

Understanding Resident Turnover in EM-IM Combined Programs

Emergency Medicine-Internal Medicine (EM IM combined) residencies are uniquely demanding. Residents split time between high-acuity emergency departments and complex inpatient/internal medicine services, often at multiple sites, with different leadership structures. In this context, resident turnover—trainees leaving the program, transferring, or not advancing—is more than a statistic; it can be an early indicator of deeper program problems.

For applicants, frequent or poorly explained turnover is a potential resident turnover red flag. It may signal issues with workload, culture, supervision, or leadership. However, not all turnover is inherently bad—life happens, career goals change, and sometimes a single resident leaving is simply a personal decision.

This guide will help you:

• Recognize warning signs of problematic turnover in Emergency Medicine-Internal Medicine combined residency programs
• Ask focused, professional questions on interview day and second looks
• Differentiate between healthy transparency and concerning patterns
• Protect your well-being and career while evaluating programs

The goal is not to make you suspicious of every change, but to help you interpret the context when you hear about residents leaving program training tracks, especially in a demanding combined specialty.

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Why Turnover Matters More in EM-IM Combined Programs

Turnover matters in every residency, but EM-IM combined programs have unique features that make it especially important to examine carefully.

1. Smaller Class Sizes, Larger Impact

Most EM-IM combined programs are small: 4–6 residents per year is common, sometimes fewer. Losing even one resident per class can mean:

• A 20–25% reduction in class size
• More shifts and call redistributed to remaining residents
• Less peer support and fewer backup options when someone is sick or struggling
• Disrupted educational experiences if rotations rely heavily on resident staffing

In larger categorical programs, a single resident leaving might be a blip. In an EM-IM combined program, it can reshape the day-to-day environment.

2. Dual Accreditation and Culture Complexity

EM-IM residents answer to:

• The Emergency Medicine (EM) program leadership
• The Internal Medicine (IM) program leadership
• The EM-IM combined program director and/or associate program directors

This triad creates more potential friction points:

• Differing expectations between departments
• Inconsistent feedback and evaluation systems
• Conflicting rotation priorities or scheduling demands

Turnover in this setting can sometimes reflect systemic coordination problems between EM and IM rather than individual resident weakness.

3. High-Intensity Training Across Two Worlds

EM IM combined training combines:

• The rapid pace and shift work of emergency medicine
• The cognitive load and continuity demands of internal medicine

This intensifies risks of:

• Burnout and moral distress
• Fatigue and circadian disruption
• Feeling “between worlds” (neither fully EM nor fully IM in social identity)

A pattern of residents leaving program training early, particularly in the mid-PGY years, can signal the program has not adequately addressed these predictable risks.

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Types of Turnover: Normal vs Concerning

Before labeling any movement as a resident turnover red flag, it helps to clarify what you’re seeing.

Normal or Understandable Turnover

Some examples of turnover that can be benign, especially if infrequent and transparent:

• Life events: Spousal relocation, major family illness, unexpected caregiving responsibilities
• Career redirection: A resident realizing EM-IM combined is not aligned with their long-term goals (e.g., wants pure EM or pure IM)
• Health issues: Medical or psychiatric conditions requiring leave, reduced schedule, or relocation
• Performance-related non-promotion: If rare and handled with clear support processes and remediation

Key characteristics of non-alarming turnover:

• Program leadership is open and factual about it (while maintaining privacy)
• It seems rare and clearly explained
• Remaining residents do not show fear or anxiety discussing it
• Faculty describe a structured remediation and support system, not a punitive culture

Concerning Turnover Patterns

Turnover becomes a red flag when it is:

• Frequent: Multiple residents leaving from consecutive classes
• Clustered: Several residents leaving or transferring within the same year or two
• Unclear or secretive: Evasive or conflicting explanations
• One-directional: Residents leaving EM-IM for other programs, but no residents transferring in

Especially concerning in EM-IM combined programs:

• Residents frequently converting to categorical EM or IM within the same institution
• Multiple residents resigning or being non-renewed without performance issues clearly cited
• Rumors of “mass exodus” or “everyone tries to switch out after PGY-1”

The more these features cluster together, the more you should carefully reassess your rank list.

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Concrete Warning Signs to Watch for on Interview Day

Understanding theory is helpful, but what can you visibly observe or ask about during interviews and second looks? Below are specific resident turnover warning signs, with a focus on EM-IM combined training.

1. Vague or Evasive Answers About Past Residents

How programs respond when you ask about prior residents leaving is extremely telling.

Questions to ask diplomatically:

• “In the past 5–7 years, have any EM-IM residents left the program or transferred elsewhere?”
• “If so, how did the program support them through that transition?”
• “How many current residents are off-cycle or on extended training plans?”

Concerning responses:

• “People leave everywhere” without any specifics
• “We don’t talk about that” or visibly uncomfortable body language
• Different stories from faculty and residents about the same situation
• Residents say, “Ask the PD about that,” and the PD later stays vague

Healthy programs can give general, de-identified explanations, such as:

“We had one resident in the last 8 years who moved for family reasons and another who realized they preferred categorical IM and transitioned smoothly with our support.”

2. High Number of Off-Cycle or Missing Residents

When you meet the residents, take stock:

• Are there missing PGY classes (e.g., no PGY-4s in a 5-year EM-IM program)?
• Are many residents “off-cycle,” extending beyond 5 years without clear reasons (e.g., research tracks or combined fellowships)?
• Do multiple residents say they started in EM-IM but are now categorical EM or IM?

Ask specific, neutral questions:

• “I noticed there are fewer PGY-3s than other classes—did some residents transfer or leave?”
• “How many residents in the last 5–10 years have finished on time versus needing extended training?”

Consistent patterns of residents leaving program pathways or not graduating on time—without clear justifications like leaves of absence, dual degrees, or research—may signal broader problems.

3. Residents Hinting at Burnout or Unsustainable Workload

EM-IM combined residents naturally work hard. But if every resident you meet seems exhausted and discouraged, that’s meaningful.

Things to listen for:

• “It gets better once you survive PGY-2.”
• “The schedule is brutal, but at least it prepares you for anything.”
• “People cry a lot in this program, but that’s just residency.”
• “We’ve had some people leave, but they just couldn’t handle it.”

Actionable approaches:

• Ask, “When residents struggle—whether academically, emotionally, or personally—how does the program respond?”
• “How easy is it to call in sick or get coverage when you’re not safe to work?”
• “Have you seen residents successfully use wellness resources here?”

Burnout is not unique to any one program, but chronic burnout with defensive rationalization is a red flag for both resident well-being and eventual turnover.

4. Discrepancies Between EM and IM Stories

In EM IM combined residencies, pay attention to alignment between EM and IM perspectives.

Potential warning signs:

• EM faculty/residents say, “We love the EM-IM folks,” while IM says, “We don’t really know what they do over there.”
• IM chiefs describe EM-IM residents as “always gone,” “not really part of our team,” or “hard to schedule.”
• EM emphasizes procedural, high-adrenaline training, while IM stresses complexity and continuity—yet neither can explain how EM-IM residents balance both effectively.

Ask:

• “How integrated are EM-IM residents into both categorical EM and IM program cultures?”
• “Do EM-IM residents hold leadership roles (chiefs, committees) in either or both departments?”
• “Have any EM-IM residents left the combined track specifically because of tension between the two departments?”

Lack of structural and cultural integration can fuel dissatisfaction and contribute to residents leaving program training tracks prematurely.

5. Frequent Leadership Turnover or Unstable Governance

Leadership change is not automatically bad—sometimes it signals improvement. However, rapid, repeated turnover in program directors or key faculty can destabilize expectations and support.

Questions to explore:

• “How long have the EM-IM program director and associate program directors been in their roles?”
• “Has there been recent leadership transition? If so, what prompted it?”
• “What changes has the new leadership implemented to improve resident support?”

Possible red flags:

• Multiple PD changes in a short period (e.g., 3 PDs in 5 years)
• Residents openly saying, “We’re waiting to see what happens,” or “Things have been chaotic.”
• No clear narrative about where the program is headed

Unstable leadership often precedes or accompanies higher resident turnover and unresolved program problems.

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How to Investigate Turnover Without Burning Bridges

You need honest information, but you also want to maintain professionalism and avoid sounding accusatory. Here are concrete tactics for exploring resident turnover warning signs effectively.

1. Use Neutral, Data-Oriented Questions

Frame your questions as curiosity about structure and outcomes, not suspicion.

Examples:

• “About how many EM-IM residents have graduated in the last 5–10 years? Have there been any who didn’t complete the program, and what were the typical reasons?”
• “How does the program track wellness and burnout, and have those efforts changed in response to prior resident feedback?”
• “Can you share approximate board pass rates and any patterns over time?”

Programs accustomed to transparency will often volunteer contextual details, including prior residents leaving program or transferring.

2. Ask Residents Privately and in Groups

Resident input is critical. Use both:

• Group sessions: Look for non-verbal cues, how residents react to each other’s comments, who speaks freely
• One-on-one moments: During tours, informal meals, or virtual breakout rooms, you can ask slightly more pointed questions

Targeted questions:

• “If you had to pick one thing the program is still actively working to improve, what would it be?”
• “Have any of your co-residents left or switched tracks? How was that handled?”
• “Do you feel safe discussing concerns with leadership without fear of retaliation?”

If multiple residents, across classes, describe similar unresolved issues (e.g., chronic understaffing, unresponsive leadership), take it seriously.

3. Look Beyond Official Interview Day

To understand resident turnover red flags and program problems more fully, use external resources:

• FREIDA, ACGME, and departmental webpages: Look at graduating class sizes year to year; unexplained drops deserve questions.
• Program alumni lists: Do graduation years show gaps? Are some classes notably small?
• Informational interviews: If possible, speak with alumni (particularly those who completed EM-IM combined) via email or LinkedIn.

When alumni or off-the-record contacts say things like “Several people left in my year” or “A lot of us tried to switch to categorical,” that’s important context.

4. Interpret Turnover in the Context of Program Response

Turnover alone isn’t the whole story. More important is how the program responds.

Ask:

• “Can you tell me about a time resident feedback led to a concrete change in scheduling, curriculum, or wellness support?”
• “What changes have been made in the last 3 years based on resident experience?”
• “Has the program adjusted call schedules, ED shift load, or ICU requirements after concerns were raised?”

Positive signals:

• Specific examples of recent, resident-driven improvements
• Admission that “We had issues in X area; here’s what we did and how we’re tracking progress”
• A track record of course correction rather than denial or blame

If a program acknowledges that residents leaving program training highlighted real weaknesses, and then clearly demonstrates sustained response, the red flag may be more of a yellow caution sign—worth monitoring, but not necessarily disqualifying.

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Balancing Risk and Opportunity When Ranking EM-IM Programs

After identifying possible warning signs, you still have to make a decision: Is this EM IM combined program a reasonable risk, or are the resident turnover patterns too concerning?

1. When Turnover Is a Serious Red Flag

Consider ranking a program lower (or not at all) if you observe:

• Multiple residents leaving from several consecutive classes
• No clear, consistent explanation for departures
• Residents discouraging you from coming there (“It’s survivable, but I wouldn’t do it again”)
• Hostile or dismissive leadership language about residents who left
• Chronic understaffing leading to unsafe situations in either the ED or inpatient wards

Remember: What you tolerate as a resident will shape your development, your health, and your career trajectory. In a 5-year EM-IM combined residency, that’s a long time to endure serious dysfunction.

2. When Turnover Is a Potential Yellow Flag

Some scenarios sit in the middle:

• One or two residents leaving over many years
• A recent spike in turnover tied to a specific, time-limited issue (e.g., COVID-era scheduling stress)
• Leadership transitions that are still stabilizing the program

In these cases, weigh:

• Trajectory: Are things clearly improving, stagnant, or worsening?
• Transparency: Are residents and faculty honest about what’s happening?
• Fit: Does the program’s clinical exposure, academic environment, and geographic location align with your personal and career priorities?

You might still rank such a program, but place it lower than more stable ones.

3. When Turnover Is Present but Well-Handled

Sometimes, a resident leaves or changes tracks, and the program truly responds constructively:

• Providing robust support and career counseling
• Redistributing workload fairly without punishing remaining residents
• Honestly reviewing root causes and adjusting systems or expectations

In EM-IM combined residencies, where demands are inherently high, a program’s ability to handle adversity thoughtfully can end up being an asset—showing that if you ever struggle, you’ll be supported.

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Practical Takeaways for EM-IM Applicants

To summarize, here are actionable steps to evaluate resident turnover warning signs in Emergency Medicine-Internal Medicine programs:

1. Do your homework

   • Review class sizes, graduation lists, and any public data on outcomes.
   • Notice missing classes, unusually small cohorts, or sudden changes.

2. Ask targeted, neutral questions

   • “Have any EM-IM residents left or changed tracks in recent years?”
   • “How did the program respond and support those residents?”
   • “What changes have you made in response to resident feedback?”

3. Observe culture, not just curriculum

   • Are residents generally honest and nuanced, or anxious and guarded?
   • Do EM and IM faculty describe EM-IM residents in aligned, respectful ways?
   • Does the program acknowledge and plan for EM-IM’s dual demands?

4. Look for patterns, not isolated stories

   • One departure for family reasons is different from multiple unexplained exits.
   • Consistent themes from multiple sources matter more than a single comment.

5. Prioritize your safety and growth

   • Any program that normalizes burnout, dismisses resident concerns, or vilifies former residents is risky.
   • Aim for environments where you are seen as a learner and a human—not simply a workforce solution.

In a combined Emergency Medicine-Internal Medicine residency, your training will be intense no matter where you go. Choosing a program with healthy transparency, stable leadership, and thoughtful responses to turnover will position you for both clinical excellence and personal sustainability.

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Frequently Asked Questions (FAQ)

1. Is any resident leaving a program automatically a red flag?

No. Residents leave programs for many reasons—family moves, health needs, or evolving career goals. One or two departures over many years, especially with clear explanations, are usually not concerning. Raise your concern level when you see patterns of residents leaving program training tracks, particularly when explanations are vague or inconsistent.

2. How many residents leaving is “too many” for an EM-IM combined program?

There’s no strict numerical cutoff, but in a small EM IM combined cohort, losing even one resident per class over several years is significant. If you see multiple residents leaving from consecutive classes—or a whole class reduced by half—that warrants detailed questions about program structure, culture, and support.

3. If a program has had serious problems in the past, should I avoid it completely?

Not necessarily. Some programs have emerged stronger after addressing prior issues. Focus less on whether problems existed and more on how the program responded:

• Did leadership change and stabilize?
• Were duty hours and workloads adjusted?
• Do current residents feel improvements are real and sustained?

If the program acknowledges past program problems and can clearly describe specific corrective measures and positive outcomes, it may still be a solid option.

4. How can I ask about resident turnover without sounding negative on interview day?

Use curious, forward-looking language and data-oriented questions:

• “I’m interested in program outcomes. Over the last 5–10 years, how many EM-IM residents have completed the program, and have there been any who transitioned to other tracks?”
• “What systems are in place to support residents who are struggling before it gets to the point of considering leaving?”
• “How has resident feedback shaped changes in scheduling, wellness, or curriculum recently?”

This shows maturity and thoughtfulness, not negativity, and helps you identify true resident turnover warning signs while preserving professional rapport.