"Junior Attending" or other independent sign out experiences in residency

[BlondeDocteur]

Hi everyone--

I'm helping my program develop a "junior attending" sure path elective for senior residents, which I have seen at a variety of other hospitals. Since we are designing it from scratch, I'd love to hear from you as to what worked and what didn't work. How did you work in 'graduated responsibility' into your residency experience? At my program, the double barrier of lost revenue and liability will mean that non-BE residents will never actually independently sign out cases (which is true for >99% of academic hospitals), so short of actually pushing the "signout" button yourself, how did you gain independent practice experience while still in training?

For the interested-- as I'm envisioning it now, final year residents will have full responsibility for the junior on a given subspecialty service. The junior will preview and sign out with the senior; the senior, after teaching/ correcting/ cleaning up the case, will then pass the slides along to the attending, who will hopefully rubber-stamp things. The senior will only work with the attending when anything is missed or large teaching points need to be made.

I see this as mutually advantageous: the senior, freed of any grossing (junior/PA) or admin/research (attending) responsibilities, will have much more time to devote to the junior's education, and will hopefully be more approachable and more amenable to going over the absolute basics, so the junior benefits. The senior gets to hone their teaching abilities, gain independence, and review key subspecialties before the boards.

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[pathstudent]

For the interested-- as I'm envisioning it now, final year residents will have full responsibility for the junior on a given subspecialty service. The junior will preview and sign out with the senior; the senior, after teaching/ correcting/ cleaning up the case, will then pass the slides along to the attending, who will hopefully rubber-stamp things. The senior will only work with the attending when anything is missed or large teaching points need to be made.

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This is how it worked where I was and overall was fine. It works well for the senior resident but sometimes the junior resident gets short changed depending on the competency/personality of the senior resident. But that is true with attendings also I suppose.

 

[BlondeDocteur]

Thanks. Any kinks I should be aware of, besides variation in general abiltity?

 

[deleted314957]

Thanks. Any kinks I should be aware of, besides variation in general abiltity?

The gov. (HHS, CLIA, TEFRA, etc) have made TRUE independent s/o impossible. We could do it 30 years ago, especially in the military system.
Your last 2 months of surg path s/o were independent, period. You were expected to consult as you would as an "adult" pathologist. If you screwed up
you were pretty much a pariah for whatever remained of your military career.

 

[Mace1370]

The gov. (HHS, CLIA, TEFRA, etc) have made TRUE independent s/o impossible. We could do it 30 years ago, especially in the military system.
Your last 2 months of surg path s/o were independent, period. You were expected to consult as you would as an "adult" pathologist. If you screwed up
you were pretty much a pariah for whatever remained of your military career.

A shame. I would much prefer to lose the safety blanket shortly before my training ended than end up somewhere and have never been truly independent like we have now.

 

[Mace1370]

Thanks. Any kinks I should be aware of, besides variation in general abiltity?

My program uses concordance sheets and any senior resident who is below a certain cutoff does not get to do senior sign out.

 

[Autopsy101]

I think that sounds like a great idea! Anything you can do as a senior to approach independent sign out will be beneficial. We don't have residents signing out with other residents in our program, but it sounds like a great idea. My personal teaching style - I don't sit to sign out with 3rd or 4th year residents unless they screw up royally or have a particularly hard or difficult case. I expect everything dictated and ready for sign out with only minor corrections. That being said, where I have run into issues with this approach is with ordering IHC or other special studies (what things the residents can order independently vs running by me first) and turn around time when the resident is way off base and either ordered the wrong stains or didn't re-submit gross tissue as needed if the specimen was inadequately grossed. If your LIS allows it, it might also be of benefit to check and prepare the billing codes to get experience with that during your "junior attending" rotation.

 

[BlondeDocteur]

Thanks! That's a good idea. We keep case logs with concordance sheets. The surg path director and I were batting around ideas re: qualifications to sign up for the elective; we were tentatively thinking about a certain cutoff on the AP portion of the prior year's RISE, but didn't want to open a can of worms re: making the RISE something punitive.

And learning about billing/coding, as painful as it is, would be extremely useful, and I definitely hadn't thought of it.

Btw @Mikesheree and others, do you think pathology is unique in cutting down on independent experience? 30 years ago, surgical residents independently took people to the OR, and medicine residents could admit, treat and discharge a patient without them ever being seen by an attending. I think the winds of change have blown this way for everyone, not just us.

 

[Alteran]

We attempted to have a junior attending month at my program when I was there spearheaded by yours truly. In theory, it would have allowed the 4th year to read slides, compose a complete diagnostic report, and forward it to the attending for review. If there was anything off with it, you would get feedback on how to improve.

In reality, it was an utter failure. The faculty, for the most part, were absolutely incapable of functioning as independent pathologists. By not having a resident at their side to scribe the diagnoses, it was as if their eyeballs fell out. There was harsh push back from about half the faculty and they refused to allow the resident to handle the cases in their absence, the time was not protected (i.e. resident calls in sick...guess whose going to do the grossing, etc.), and the level of disorganization on part of the institution and certain faculty precluded any meaningful experience. The experiment was promptly terminated.

I sincerely hope your experiment works out better than ours did and becomes a valuable learning experience. I will tell you that while you might think you know how to put a report together when you leave residency, you won't actually know how hard and nuanced it can be until you have to do it your name attached to it.

 

[deleted314957]

Thanks! That's a good idea. We keep case logs with concordance sheets. The surg path director and I were batting around ideas re: qualifications to sign up for the elective; we were tentatively thinking about a certain cutoff on the AP portion of the prior year's RISE, but didn't want to open a can of worms re: making the RISE something punitive.

And learning about billing/coding, as painful as it is, would be extremely useful, and I definitely hadn't thought of it.

Btw @Mikesheree and others, do you think pathology is unique in cutting down on independent experience? 30 years ago, surgical residents independently took people to the OR, and medicine residents could admit, treat and discharge a patient without them ever being seen by an attending. I think the winds of change have blown this way for everyone, not just us.

I am sure it changed for all. You are certainly correct about surg and med 30 years ago. That is how it was when I was a surg intern.

 

[BlondeDocteur]

@Alteran that is sobering. Luckily we're not resident-dependent on grossing and the sheer size of our program means that most faculty frequently have weeks where their particular subspecialty isn't covered, so they are quite competent at functioning independently.