Summary of new ACGME program requirements (effective July 1, 2020)

[Krukenberg]

Hadn't seen this posted. Here's a good summary of the changes to program requirements that will be put in place starting July 1.

https://www.acgme.org/Portals/0/PFA..._PR-Changes2019.pdf?ver=2019-08-26-120824-023

There aren't any changes that are blatantly obvious at reducing the # of programs, but overall it places a number of more stringent requirements and increases in case #s that will squeeze small programs and increase the cost of expanding the # of residency slots. IMO I think the changes will also result in higher quality residency programs on average.

A few of the changes that will increase the burden of having a residency program (and maybe prompt small programs to close):
- Required increase in protected %effort for program directors (decreases clinical revenue for departments with a residency program).
- Increased % protected effort required for program coordinators (for the first time there is a minimum % effort, and it increases according to # of residents, thus making it more costly to have more residents)
- Increase # of brachy and radiopharmaceutical cases
- Increased scholarly activity requirement for both faculty and residents
- Increased the ceiling for max # of simulations per resident in a given year, thus reducing the incentive for departments to expand due to clinical workload (but at the cost of more work per resident)

Overall it's a good start, and as long as the ACGME enforces the requirements it will lead to positive changes. I have no doubts the chicken littles will bash these changes though.

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[deleted1002574]

Everything is underwhelming. Just give up. Everything sucks. No one is trying hard enough to please you all. It should be 0 residents by yesterday, every program should be as good as CCF (or pick your program du jour) or it should just shut down. The requirements should be perfect and should train the perfect resident, the perfect number of residents, and they should be perfectly proportionately distributed to every part of the 50 states. Idealized version of Rad onc = Lake Wobegon ...

 

[Tigerstang]

"Section III: Resident Appointments The proposed requirements included an increase in the minimum number of resident positions offered by the programs. This increase was removed in the final requirements submitted by the Review Committee. The Program Requirements remain unchanged, in that programs must offer at least four resident positions [PR III.B.2] "

yup

 

[deleted956486]

Gotta start somewhere.

 

[evilbooyaa]

Everything is underwhelming. Just give up. Everything sucks. No one is trying hard enough to please you all. It should be 0 residents by yesterday, every program should be as good as CCF (or pick your program du jour) or it should just shut down. The requirements should be perfect and should train the perfect resident, the perfect number of residents, and they should be perfectly proportionately distributed to every part of the 50 states. Idealized version of Rad onc = Lake Wobegon ...

Agree with this. At least a (minimal) step in the right direction.

Agree that the resident complement increase being shut down is good as well.

However, seems like ACGME is playing at the wallet of a residency program (based on the points Krukenberg highlighted) rather than the case load to induce contractions/closures as has been recommended multiple times by me and others on this forum (and more recently on twitter). This is a mistake, as residents will always be cheaper than PAs.

I am doubtful that any program will close because of a % effort requirement increase for the PD. I think it's essentially a guarantee that a % effort requirement increase for a PC will cause a program to close. No chance a program contracts because the financials of having increased % effort of a PC (PD can still be at the same % effort) for an additional 1-4 residents.

 

[deleted956486]

Agree with this. At least a (minimal) step in the right direction.

Agree that the resident complement increase being shut down is good as well.

However, seems like ACGME is playing at the wallet of a residency program (based on the points Krukenberg highlighted) rather than the case load to induce contractions/closures as has been recommended multiple times by me and others on this forum (and more recently on twitter). This is a mistake, as residents will always be cheaper than PAs.

I am doubtful that any program will close because of a % effort requirement increase for the PD. I think it's essentially a guarantee that a % effort requirement increase for a PC will cause a program to close. No chance a program contracts because the financials of having increased % effort of a PC (PD can still be at the same % effort) for an additional 1-4 residents.

Disagree that case load will change anything. Where I trained (and I think where most people train) we made up numbers. No one is gonna risk not graduating because of cases.

 

[evilbooyaa]

Disagree that case load will change anything. Where I trained (and I think where most people train) we made up numbers. No one is gonna risk not graduating because of cases.

Made up case numbers? Like completely fabricated cases to reach your minimums? I don't do that. I've never done that. I can't say that I've spoken to other residents about this but I would be shocked if this is at all routine. I would try to get a request like that in writing and report my program to the ACGME and RRC if they asked me to do that because they weren't providing me the educational experience that was agreed upon. I also don't agree with double logging of say a brachy case by multiple residents. Perhaps ACGME needs to do a deep audit of every RO residency program.

I'm not talking about increasing the minimums for EBRT (although I have advocated for site specific minimums across major disease sites), mostly increases in brachy, SRS, and SBRT. Large, like 5-10 fold increases in them is what I'm talking about.

 

[scarbrtj]

This, along with a perhaps newly trending ~1% drop in resident numbers per year, will bear job market fruits 10-20 years from now. Do suggest med students keep checking in from time to time. Because if smoking rates level off, and if APM not too hurtful, and if "fractionation" stabilizes, and if rad onc utilization stabilizes, rad onc will probably be reasonably attractive middle of next decade.

 

[Aphtalyfe]

Agree with this. At least a (minimal) step in the right direction.

Agree that the resident complement increase being shut down is good as well.

However, seems like ACGME is playing at the wallet of a residency program (based on the points Krukenberg highlighted) rather than the case load to induce contractions/closures as has been recommended multiple times by me and others on this forum (and more recently on twitter). This is a mistake, as residents will always be cheaper than PAs.

I am doubtful that any program will close because of a % effort requirement increase for the PD. I think it's essentially a guarantee that a % effort requirement increase for a PC will cause a program to close. No chance a program contracts because the financials of having increased % effort of a PC (PD can still be at the same % effort) for an additional 1-4 residents.

I'm a little confused by the %effort/FTE calculations. If a PD/PC makes X / year in salary... now that there are new requirements, wouldn't a program just change the way the pie is sliced?

So instead of 90/10, where 90% is non-PD work and 10% is PD work... they just redistribute the total salary to make it 80/20?
For a PC who is supposed to be getting 50% salary support... wouldn't they just reduce his salary for non-PC duties and increase the PC salary support... so that the total is still the same salary they had before?

 

[evilbooyaa]

I suppose most of that is driven by how much protected time the PD and PC are expected to have rather than a salary component. Meaning the PD can't see as many patients in clinic, PC can't do as much non-residential secretarial stuff. May require hiring of additional staff to cover the clinical and secretarial responsibilities being vacated.

 

[seper]

20% FTE is good chunk of change. Quite a few of the smallish RadOnc programs (I know at least 3 personally) are based at private-practice types of places, where the total pay per attending is c. 450-500 K.

 

[deleted774703]

Made up case numbers? Like completely fabricated cases to reach your minimums? I don't do that. I've never done that. I can't say that I've spoken to other residents about this but I would be shocked if this is at all routine. I would try to get a request like that in writing and report my program to the ACGME and RRC if they asked me to do that because they weren't providing me the educational experience that was agreed upon. I also don't agree with double logging of say a brachy case by multiple residents. Perhaps ACGME needs to do a deep audit of every RO residency program.

I'm not talking about increasing the minimums for EBRT (although I have advocated for site specific minimums across major disease sites), mostly increases in brachy, SRS, and SBRT. Large, like 5-10 fold increases in them is what I'm talking about.

im equally surprised to see making up case numbers

how does ACGME even know if cases are legit?

do they audit programs?

 

[Chartreuse Wombat]

One day a week to manage four residents? Neha is making it more expensive to have a program which hopefully will lead many of the smaller programs to leave the business as margins continue to fall.

 

[Neuronix]

So just cram more patients into the other work days. Been there, done (and doing) that.

 

[Krukenberg]

So just cram more patients into the other work days. Been there, done (and doing) that.

I'm a little confused by the %effort/FTE calculations. If a PD/PC makes X / year in salary... now that there are new requirements, wouldn't a program just change the way the pie is sliced?

So instead of 90/10, where 90% is non-PD work and 10% is PD work... they just redistribute the total salary to make it 80/20?
For a PC who is supposed to be getting 50% salary support... wouldn't they just reduce his salary for non-PC duties and increase the PC salary support... so that the total is still the same salary they had before?

20% FTE means the department is eating the cost of 1 clinic day's worth of salary. At my institution and I imagine most places, they also decrease the productivity goal, which obviously decreases the clinical revenue that faculty member generates. It's not an insignificant amount of money.

Any prospective PD who accepts the position without a commensurate decrease in productivity goal is a sucker. Any department, especially ones that aren't very academic, would have to do that to convince someone to take the PD position.

 

[Krukenberg]

Disagree that case load will change anything. Where I trained (and I think where most people train) we made up numbers. No one is gonna risk not graduating because of cases.

Wow! That is at best a gross violation of ACGME standards and at worst a federal crime if Medicare pays for any of the residents' salaries. That program will be shut down instantly if residents reported being induced to make up cases.

 

[Krukenberg]

If we assume that residents are equivalent to PA's in terms of value to an academic practice, and ignoring Medicare funds, then $120k x 4 residents is $480k/year.

As I talk to more of our graduated residents who are out as attendings now, the more skeptical I am that residents are universally a net positive for productivity of attendings. A bad resident on your service for 2 months at a time seems to be worse than having no resident at all or a PA you've trained up to do what you want very well. I think GOOD residents are definitely a net positive, but the quality can vary dramatically. If small programs are consistently getting residents who wanted to do derm but SOAPed in, they may decide it's more trouble than it's worth to have a residency program.

 

[deleted956486]

Wow! That is at best a gross violation of ACGME standards and at worst a federal crime if Medicare pays for any of the residents' salaries. That program will be shut down instantly if residents reported being induced to make up cases.

Smoking gun right there-didn't hear it from me tho, ya heard?

 

[deleted1002574]

The right thing to do for rad onc is to tell us what program. Will get rid of 4-20 spots, depending on who it is (rooting for one of the big ones!)

 

[Krukenberg]

The right thing to do for rad onc is to tell us what program. Will get rid of 4-20 spots, depending on who it is (rooting for one of the big ones!)

herein lies the problem. Should the big, well-resources departments be the ones cutting spots? IMO it should be low quality programs we cut. Certainly expansion of long-standing programs contributed to the problem, but now I don’t think the right answer is to cut the amount of good training spots.

 

[evilbooyaa]

herein lies the problem. Should the big, well-resources departments be the ones cutting spots? IMO it should be low quality programs we cut. Certainly expansion of long-standing programs contributed to the problem, but now I don’t think the right answer is to cut the amount of good training spots.

Completely agree with you that we should only cut spots from low quality programs. How do you define a low quality program? Is it only dependent on the size of the program? Is every program with 4 total residents a low quality program? Is every program with 8 or more residents obligatorily NOT a low quality program?

I would argue departments with an equal number of residents to attendings is a low quality program (or worse yet, programs that have MORE residents than attendings!! - I will be creating a new thread to discuss this further). Departments that don't have attendings that work uncovered for 2-3 months out of the year so as to not be 'resident dependent' are low quality programs. Programs that are so large that, even if they had appropriate brachy volume for say 6 residents, there is not enough brachy volume for the 8-10 residents they have so that residents have to double log cases so everyone can meet numbers. Programs where interviewees go and the residents are NOT happy and DON'T have good things to say about the program - those are low quality programs, IMO.

But, I know that for the academic machine, a lot of these factors are surprising, especially like expecting attendings to work without a resident to run their service. That is why I have frequently recommended that case load requirements need to increase significantly, and we let the chips fall where they may.

 

[deleted774703]

herein lies the problem. Should the big, well-resources departments be the ones cutting spots? IMO it should be low quality programs we cut. Certainly expansion of long-standing programs contributed to the problem, but now I don’t think the right answer is to cut the amount of good training spots.

A big department with a lot of resources is not necessarily a good learning environment

there was a solid 5 to 10 year span where Emory was completely malignant to the point where they actually got a ACGME violation

Only after the violation did things improve for residents

We need to stop this assumption about large programs ASAP

if you stink, you stink and you should be demolished

 

[deleted941485]

Disagree that case load will change anything. Where I trained (and I think where most people train) we made up numbers. No one is gonna risk not graduating because of cases.

Where I trained if you saw the consult you were pressured tk
Log it. Older programs did the same.

I know PGY 2 logging 300 cases there first year. It’s a garbage system.

The only way to stop it is the make the administrative burden so great for PDs that they literally just give up.

 

[Music Man Stan]

I just wanted to comment about the new rule that allows 350 cases a year. I know firsthand how it feels to have 350+ ext beam a year and it is really quite unpleasant especially if you’re actually reviewing plans, have a brachy heavy training, reviewing films, going to daily didactics, and seeing followups. 350 might be reasonable at programs where they have minimal didactics, minimal brachy, rarely see follow ups or do good plan review but geezes raising that max is going to make quality of life a whole ****ton worse for residents.