Proposed Section Structure
This topic is best addressed as a clinically grounded commentary rather than a traditional trial summary. A logical structure includes: clinical context and burden; article type and central thesis; historical evolution of boarding and crowding; implications for resident education; practical educational adaptations; critical appraisal and implementation challenges; and a concise conclusion with references.
Highlights
Boarding and emergency department crowding are long-standing structural problems, not temporary post-pandemic disruptions. Schor, Baez, and Hill argue that residency programs should stop treating these conditions as aberrations and instead deliberately prepare trainees to practice safely within them. The educational opportunity is not to normalize unsafe systems, but to teach prioritization, communication, flow management, triage decision-making, and supervision strategies that are now central to modern emergency medicine. The key tension is preserving educational quality and patient safety while avoiding resignation to system failure.
Background and Clinical Context
Emergency department crowding and boarding have been described for decades, with consistent evidence linking them to delayed care, prolonged length of stay, ambulance diversion, treatment delays, medical error risk, worsened patient experience, and, in some studies, higher mortality. The conceptual framework proposed by Asplin and colleagues divided crowding into input, throughput, and output factors; boarding is primarily an output failure, reflecting an inability to move admitted patients to inpatient beds. This distinction matters because many local ED process improvements cannot overcome hospital-wide capacity constraints.
The COVID-19 era intensified public and professional awareness of boarding, but the underlying problem predates the pandemic by many years. In practical terms, residents training in emergency medicine increasingly learn in departments where hallway care, extended observation of admitted patients, fragmented handoffs, and prolonged waiting room times are commonplace. The educational environment is therefore inseparable from operational stress. The question posed by Schor and colleagues is timely: if boarding is likely to remain endemic, should residency education explicitly adapt?
Article Type and Central Thesis
The Annals of Emergency Medicine article by Schor S, Baez J, and Hill is a perspective-style analysis rather than an original interventional study. Its core argument is straightforward but consequential: emergency medicine education has devoted substantial attention to how crowding harms resident learning, yet relatively less attention has been paid to how training should change in response. The authors suggest a paradigm shift from viewing boarding as a temporary deviation from ideal emergency care to acknowledging it as a recurring feature of contemporary practice that trainees must be equipped to navigate.
This is not a claim that boarding is acceptable. Rather, it is a pragmatic educational position. Residents will become attendings in systems where they must supervise teams, manage waiting rooms, communicate risk under conditions of delay, and coordinate care for both undifferentiated arrivals and boarded inpatients. The educational agenda, therefore, should expand beyond the traditional model of bedside diagnostic reasoning within a relatively controlled patient flow environment.
How Understanding of Boarding Has Evolved
The literature on crowding has evolved from describing the problem to quantifying its consequences and, more recently, to identifying hospital-level causes. Earlier work often focused on ED volume and operational inefficiency. Over time, evidence increasingly showed that crowding is driven substantially by access block and inpatient capacity mismatch rather than excessive ED use alone. This reframing has major implications for training: residents must understand crowding not merely as “too many patients,” but as a systems-level failure spanning inpatient throughput, discharge bottlenecks, staffing, and institutional incentives.
Educational discussions have historically emphasized what crowding takes away from trainees: fewer teaching moments, reduced bedside supervision, procedural competition, cognitive overload, and pressure to prioritize speed over reflection. Those concerns remain valid. But the Schor commentary highlights a gap in the literature: relatively little work has centered on the competencies required to practice effectively under chronic crowding. In other words, graduate medical education has been more successful at documenting the educational injury of crowding than at designing a curriculum for the world crowding has created.
Why This Matters for Residency Education
The modern emergency physician does far more than evaluate one patient at a time. In a boarded department, attendings and senior residents must constantly reprioritize care, distinguish time-sensitive illness from acceptable delay, supervise care across disparate physical spaces, coordinate with nursing and consultants, manage dissatisfied patients and families, and maintain attention to high-risk transitions. These are not peripheral skills. They are core competencies in practice environments shaped by chronic occupancy strain.
From an educational perspective, several domains deserve explicit attention.
First, residents need structured training in dynamic triage and queue management. This includes identifying who can safely wait, who needs immediate room placement, and which diagnostic or therapeutic steps can begin before a traditional roomed evaluation. The rise of physician-in-triage and related front-end models creates authentic opportunities for learners to practice rapid risk stratification.
Second, residents need better preparation for longitudinal responsibility over boarded patients. Once admitted patients remain in the ED for many hours, emergency clinicians often function in a hybrid role, continuing resuscitation, reassessment, escalation, and cross-disciplinary communication. Residency training should acknowledge this reality and teach the boundaries, risks, and communication expectations associated with prolonged ED-based inpatient care.
Third, communication skills become even more important during crowding. Residents must learn to explain delays honestly, preserve trust despite throughput failure, and communicate uncertainty and contingency plans to patients, nurses, consultants, and incoming teams. These are patient-safety skills, not merely service-recovery gestures.
Fourth, crowding changes supervision itself. Attendings may have less uninterrupted teaching time, and residents may make more independent micro-decisions. Programs therefore need intentional strategies to maintain feedback quality and diagnostic calibration in chaotic settings.
Practical Educational Adaptations Proposed by the Commentary
The article’s practical value lies in encouraging programs to treat crowding-related work as teachable rather than purely corrosive. Several educational adaptations follow from that stance.
1. Build crowding-specific competencies into the curriculum
Programs can formalize learning objectives around triage thinking, waiting room reassessment, escalation thresholds, crisis communication, and management of boarded patients. These competencies can be mapped to existing emergency medicine milestones, especially systems-based practice, multitasking, team leadership, and patient safety.
2. Use physician-in-triage models as teaching platforms
When implemented safely, front-end physician evaluation can help residents learn focused assessment, rapid disposition thinking, and risk-based test ordering. Educational safeguards matter: novice learners may need closer supervision to avoid premature closure or overtesting in highly compressed encounters.
3. Teach operational literacy
Residents should understand the mechanics of ED flow, hospital bed management, escalation pathways, transfer constraints, and metrics such as door-to-provider time, left-without-being-seen rates, and boarding duration. Operational fluency is increasingly part of clinical competence.
4. Reframe boarded patients as ongoing emergency medicine responsibility
Although inpatient teams assume definitive admitting responsibility, ED residents still need to monitor clinical deterioration, revisit analgesia and symptom control, identify gaps in orders, and manage adverse events while patients remain physically in the department. Training should make this responsibility explicit.
5. Debrief cognitive load and moral distress
Crowding can create frustration, compromised professionalism, and burnout risk. Faculty debriefing after high-strain shifts may help trainees process unsafe-feeling situations, recognize system contributors, and distinguish adaptive prioritization from normalization of deviance.
6. Preserve educational quality through microteaching
In crowded settings, traditional case conferences at the bedside may be less feasible. Short, high-yield teaching bursts, targeted feedback after triage decisions, and shift-end reflection may better fit operational reality.
Critical Appraisal
The major strength of this commentary is its realism. It addresses the emergency department that residents actually inhabit rather than the one educators wish existed. That perspective is clinically relevant and likely to resonate with training programs struggling to maintain educational standards amid persistent capacity strain.
A second strength is its systems orientation. By focusing on boarding as an inevitability of current practice, the article pushes educators to broaden emergency medicine identity beyond episodic diagnosis and procedure performance. It places operations, communication, and adaptive leadership closer to the center of training.
At the same time, the argument carries important risks and limitations. Calling boarding an inevitability may be interpreted by some institutions as passive acceptance of a harmful status quo. Educational adaptation must not become an excuse to stop advocating for hospital-wide capacity solutions, inpatient throughput reform, or safer staffing. Residents should be taught to function in crowded systems and to recognize those systems as remediable policy failures.
Another limitation is the scarcity of robust interventional evidence showing which educational strategies work best during crowding. Much of the literature describes associations between crowding and reduced teaching or learner satisfaction, but fewer studies test curriculum redesigns with meaningful outcomes such as diagnostic performance, patient safety events, milestone attainment, or burnout. The field therefore remains conceptually persuasive but empirically underdeveloped.
Translational Implications for Clinicians and Training Leaders
For residency leaders, the practical message is to stop relying on an implicit curriculum. If residents are already learning in boarded departments, educators should name the competencies involved, supervise them deliberately, and assess them explicitly. This may include simulation of waiting room deterioration, workshops on communicating delays, or direct observation tools for triage and flow decisions.
For frontline attendings, the article is a reminder that operations and education are not competing domains. Teaching a resident how to identify the sickest waiting-room patient, how to hand off a boarded septic patient safely, or how to negotiate an urgent consultant evaluation during saturation is clinically meaningful education.
For health systems and policymakers, the commentary should not be read as educational accommodation alone. Persistent boarding remains a quality-of-care problem. The educational response should complement, not replace, system reform.
Conclusion
Schor, Baez, and Hill offer a timely and pragmatic reframing of resident education in emergency medicine. Their central point is difficult to dismiss: boarding and crowding are now enduring features of the training environment, and residency programs must prepare graduates accordingly. The most important contribution of the article is not that it normalizes crowding, but that it distinguishes preparation from surrender. Emergency medicine educators should teach residents how to provide safe, humane, and prioritized care in constrained environments while continuing to advocate forcefully for structural solutions that make such adaptation less necessary.
Funding and Trial Registration
No ClinicalTrials.gov registration applies to this commentary article. Funding information was not provided in the source abstract available via PubMed.
References
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