ACGME's proposed changes to FM

[Sardonix]

Stolen from reddit.

• The program director should integrate multiple non-physician professionals to augment education as well as inter-professional team clinical services. (Professions may include, but are not limited to NPs, CNSs, PAs, CNM, behavioral health, pharmacists, lab technicians.) (Detail)
• Residents must have at least 200 hours (or two months) 100 hours (or one month) of and 250 patient encounters dedicated to the care of experience with the care of acutely ill child children in the hospital and/or emergency setting. (Core) [previously IV.C.8.] (reducing the min inpatient encounters from 75 to 50, and min ED encounters from 75 to 50)
• Residents must have at least 100 hours (or one month) or 125 patient encounters an experience dedicated to the care of women with gynecologic issues, including well-woman care, family planning, contraception, and options counseling for unintended pregnancy. (Core) [previously IV.C.13.]
• Residents must have at least 100 hours (or one month) or 15 encounters dedicated to participate in the care of ICU patients hospitalized in a critical care setting. (Core) [previously IV.C.5.a)]
• Residents must have at least 200 (or two months) 100 hours of emergency department experience and at least 250 125 patient encounters dedicated to the care of acutely ill or injured adults in an emergency department setting. (Detail)(Core) [previously IV.C.6.a)]
• Residents must have at least 100 hours (or one month) an experience dedicated to the care of surgical patients, including hospitalized surgical patients. (Core) [previously IV.C.11.]
• Residents must have at least 200 hours (or two months) an experience dedicated to the care of patients with a breadth of musculoskeletal problems, including: (Core) [previously IV.C.12] (this includes dedicated experiences with Ortho and Sports)

https://www.acgme.org/globalassets/pfassets/reviewandcomment/120_familymedicine-_2021-12_impact.pdf

Comment link: Comment on Proposed ACGME Revisions to the Family Medicine Program Requirements

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[DrSpine]

Not FM, but came on here after I saw the post on Reddit and figured it would be here. This is absolutely ridiculous, illogical, and shame on the ACGME for being in bed with private equity and those that wish to destroy FM and healthcare as we know it in favor of cheaper midlevel labor, and becoming a referral monkey.

 

[smq123]

Not FM, but came on here after I saw the post on Reddit and figured it would be here. This is absolutely ridiculous, illogical, and shame on the ACGME for being in bed with private equity and those that wish to destroy FM and healthcare as we know it in favor of cheaper midlevel labor, and becoming a referral monkey.

Basically.

"We really want scutmonke....I mean, residents, at our hospitals....but it's just soooo much trouble and money to fulfill all those stupid ACGME requirements! How do we fix this.....

We'll just lower the requirements!! Brilliant!!"

 

[Captain_Falcon]

What does "proposed changes" mean? I'm guessing it is far from a guarantee so what are the odds of this happening?

 

[hallowmann]

Looking into this a bit more, here are other problematic changes:

‐-----------------------
Requirement #: II.B.1.c)-II.B.1.d).(2) Requirement Revision (significant change only): II.B.1.c) All programs must have family medicine physician faculty members role modeling and teaching and providing broad spectrum family medicine that meets the mission of the program. (Core) II.B.1.c).
**So they're just eliminating the term physicians, seemingly in a way open the door to only having FM "faculty members" that fulfill this role. Maybe I'm reading too much into it, but why eliminate just the term physician?**

(1) maternal child health care, including deliveries; (Core) II.B.1.c).

(2) inpatient adult medicine care; and, (Core) II.B.1.c).

(3) care to inpatient children. (Core)
**This stuff basically was moved to different places in the requirements and reduced as in the OP, so it's probably not a big deal being removed from just this part.**

II.B.1.d) All programs must have family medicine faculty members role modeling competence in their respective scope of practice. (Core)

II.B.1.d.(1) Programs should have family medicine faculty members providing care outside of an FMP, including skilled nursing facilities, hospital care, and home-based care. (Detail)

II.B.1.d.(2) Programs providing maternity care competency training to the level of independent practice must have at least one family physician faculty member providing family-centered maternity care, including prenatal, intra-partum, vaginal delivery, and post-partum care. (Core)

**So basically only programs that are interested in providing this care need to and ones that don't, don't need to. This reeks of minimizing the responsibility/cost of programs to actually provide necessary components of FM training. I mean they all but say it in their explanation: "Some programs may choose to limit faculty members’ scope of care to meet a program aim. For example, a program that does not intend to educate and train residents in independent maternity care may choose not to include a faculty member who performs maternity care. This may save expenses in some programs, particularly in regions were recruitment is challenging or malpractice insurance coverage is cost prohibitive."**

‐-----------------------
II.B.3.e) The program director should integrate multiple non-physician professionals to augment education as well as inter-professional team clinical services. (Professions may include, but are not limited to NPs, CNSs, PAs, CNM, behavioral health, pharmacists, lab technicians.) (Detail)

**I get the value of interprofessional teams especially in the realm of behavioral health and pharmacy, but NPs, PAs and CNMs are not adding specialized knowledge/ training. This is basically a way for programs to save money by hiring non-physicians instead of actually having more physician faculty.**
‐-----------------------

Honestly after reviewing all the changes, most of them seem pretty positive. They're actually adding some more specific OB care recommendations, expanding a lot of Behavioral Health/SUD requirements, incorporating telehealth, etc. With the exception of the stuff above and in the OP, the changes seem either reasonable or even positive.

I encourage people to review the whole document, and in comments for the revisions focus primarily on the problematic ones in this thread.

 

[deleted87716]

Supposedly, the reduction in required case numbers was driven by the pandemic, as residents have had difficulty meeting requirements due to low patient volumes. I dunno. I'm still busy.

 

[VA Hopeful Dr]

Supposedly, the reduction in required case numbers was driven by the pandemic, as residents have had difficulty meeting requirements due to low patient volumes. I dunno. I'm still busy.

I would wager its more about inpatient/ED non-adult cases than anything.

 

[thatonegrrl]

This is deeply concerning to me as someone who has spent the last 5 years working towards going to med school because I wanted to do full scope primary care to serve rural and underserved communities. I have zero interest in being a referral monkey with a scope of practice equal to an NP or PA but with 4x the debt and double the time spent in training.

I am honestly having to now drastically re-think my career goals right on the cusp of going to med school. I have literally just a month or so to decide where I want to attend to have the best chance at being the sort of physician I want to be. The proposal leaves me with no idea of how to move forward. Because I do not want this brand of "family medicine" at all.

 

[deleted941485]

This is deeply concerning to me as someone who has spent the last 5 years working towards going to med school because I wanted to do full scope primary care to serve rural and underserved communities. I have zero interest in being a referral monkey with a scope of practice equal to an NP or PA but with 4x the debt and double the time spent in training.

I am honestly having to now drastically re-think my career goals right on the cusp of going to med school. I have literally just a month or so to decide where I want to attend to have the best chance at being the sort of physician I want to be. The proposal leaves me with no idea of how to move forward. Because I do not want this brand of "family medicine" at all.

I applaud you for taking the time to rethink your decision. Many premeds are so blinded by the whole process it’s seems all their critical faculties have been suspended.

Family medicine is on the forefront of fields being degraded on all sides. I have seen other programs like peds residencies at low level programs that heavily utilize NPs and PAs as faculty where you actually have rotations with them as some or a good portion of your residency. No one complains and no one would because it would jeopardize your ability to get a job if you let on this is happening.

My guess is people have been fudging the training hours and utilizing mid levels as faculty for quite some time. This just allows existing programs to stop hiding and allows new programs to open up.

It’s surprising considering even in the community the sheer number of fam med programs already out there.

That being said there are other fields in which you can still be a PCP. IM comes to mind so does OBGYN. Pediatrics too.

 

[Sardonix]

II.B.3.e) The program director should integrate multiple non-physician professionals to augment education as well as inter-professional team clinical services. (Professions may include, but are not limited to NPs, CNSs, PAs, CNM, behavioral health, pharmacists, lab technicians.) (Detail)

**I get the value of interprofessional teams especially in the realm of behavioral health and pharmacy, but NPs, PAs and CNMs are not adding specialized knowledge/ training. This is basically a way for programs to save money by hiring non-physicians instead of actually having more physician faculty.**

In my experience, "interprofessional" learning environments like this that were mandatory in my med school years just turned into everyone s***ing on the med students and talking how they could do ____ without us. Most of the time our response would have to be something along the lines of, "Wow, great--anyway back to the patient case discussion unrelated to that." So as a heuristic I am now extremely wary of inter-professionalism as a buzz word.

Supposedly, the reduction in required case numbers was driven by the pandemic, as residents have had difficulty meeting requirements due to low patient volumes. I dunno. I'm still busy.

Remember that is the difference between a private practice and a residency clinic. Our case numbers are WAY down--partly because of COVID alone, partly because of the inherent inefficiency built into a resident clinic (lower cost but then longer wait times, fewer staff, less resources, no guarantee you'll see your actual assigned PCP et.c) being amplified by COVID. We currently have TWO medical assistants helping to cover sometimes 6-8 residents in a clinic shift. We simply cannot draw the same resources as a fully staffed and funded private practice.

 

[hallowmann]

In my experience, "interprofessional" learning environments like this that were mandatory in my med school years just turned into everyone s***ing on the med students and talking how they could do ____ without us. Most of the time our response would have to be something along the lines of, "Wow, great--anyway back to the patient case discussion unrelated to that." So as a heuristic I am now extremely wary of inter-professionalism as a buzz word.


Remember that is the difference between a private practice and a residency clinic. Our case numbers are WAY down--partly because of COVID alone, partly because of the inherent inefficiency built into a resident clinic (lower cost but then longer wait times, fewer staff, less resources, no guarantee you'll see your actual assigned PCP et.c) being amplified by COVID. We currently have TWO medical assistants helping to cover sometimes 6-8 residents in a clinic shift. We simply cannot draw the same resources as a fully staffed and funded private practice.

Yeah, but interdisciplinary teams actually are helpful, like rounding with pharmacists, seeing patients in an integrated clinic with SW and psychologists, etc. The issue is that this seems to be pushing a different agenda that does not help to expand resident training.

As for clinic, our clinics have been full capacity since June 2020. Save many people calling in sick lately, our clinics are staying pretty busy.

 

[thatonegrrl]

I applaud you for taking the time to rethink your decision. Many premeds are so blinded by the whole process it’s seems all their critical faculties have been suspended.

Family medicine is on the forefront of fields being degraded on all sides. I have seen other programs like peds residencies at low level programs that heavily utilize NPs and PAs as faculty where you actually have rotations with them as some or a good portion of your residency. No one complains and no one would because it would jeopardize your ability to get a job if you let on this is happening.

My guess is people have been fudging the training hours and utilizing mid levels as faculty for quite some time. This just allows existing programs to stop hiding and allows new programs to open up.

It’s surprising considering even in the community the sheer number of fam med programs already out there.

That being said there are other fields in which you can still be a PCP. IM comes to mind so does OBGYN. Pediatrics too.

Chalk it up to being a non-trad with a whole career in another field already under my belt.

Med-Peds, Gen Peds and Psych (including Peds Psych and FM/Psych) were already other residency pathways I was interested in. But as I try to decide where to attend I am looking more towards schools that are going to give me the best chance to match into those more competitive/limited spot combined residencies. I may still end up going for FM or Gen Peds, but I want to be sure I have the best chance for something else more competitive too.

I've had interviews with a couple schools leading in both primary care and pediatrics so I'm hoping I will hear good news from both of them.

 

[livingstonebridge10]

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[Cranjis McBasketball]

Chalk it up to being a non-trad with a whole career in another field already under my belt.

Med-Peds, Gen Peds and Psych (including Peds Psych and FM/Psych) were already other residency pathways I was interested in. But as I try to decide where to attend I am looking more towards schools that are going to give me the best chance to match into those more competitive/limited spot combined residencies. I may still end up going for FM or Gen Peds, but I want to be sure I have the best chance for something else more competitive too.

I've had interviews with a couple schools leading in both primary care and pediatrics so I'm hoping I will hear good news from both of them.

I mean, even if these are the requirements, there will be tons of programs that are way above them. Programs arent going to automatically lower their standards just because of these changes. This will just make it so sub-par programs with accreditation warnings slide on by

 

[Mitch Connor]

Looking into this a bit more, here are other problematic changes:

‐-----------------------
Requirement #: II.B.1.c)-II.B.1.d).(2) Requirement Revision (significant change only): II.B.1.c) All programs must have family medicine physician faculty members role modeling and teaching and providing broad spectrum family medicine that meets the mission of the program. (Core) II.B.1.c).
**So they're just eliminating the term physicians, seemingly in a way open the door to only having FM "faculty members" that fulfill this role. Maybe I'm reading too much into it, but why eliminate just the term physician?**

(1) maternal child health care, including deliveries; (Core) II.B.1.c).

(2) inpatient adult medicine care; and, (Core) II.B.1.c).

(3) care to inpatient children. (Core)
**This stuff basically was moved to different places in the requirements and reduced as in the OP, so it's probably not a big deal being removed from just this part.**

II.B.1.d) All programs must have family medicine faculty members role modeling competence in their respective scope of practice. (Core)

II.B.1.d.(1) Programs should have family medicine faculty members providing care outside of an FMP, including skilled nursing facilities, hospital care, and home-based care. (Detail)

II.B.1.d.(2) Programs providing maternity care competency training to the level of independent practice must have at least one family physician faculty member providing family-centered maternity care, including prenatal, intra-partum, vaginal delivery, and post-partum care. (Core)

**So basically only programs that are interested in providing this care need to and ones that don't, don't need to. This reeks of minimizing the responsibility/cost of programs to actually provide necessary components of FM training. I mean they all but say it in their explanation: "Some programs may choose to limit faculty members’ scope of care to meet a program aim. For example, a program that does not intend to educate and train residents in independent maternity care may choose not to include a faculty member who performs maternity care. This may save expenses in some programs, particularly in regions were recruitment is challenging or malpractice insurance coverage is cost prohibitive."**

‐-----------------------
II.B.3.e) The program director should integrate multiple non-physician professionals to augment education as well as inter-professional team clinical services. (Professions may include, but are not limited to NPs, CNSs, PAs, CNM, behavioral health, pharmacists, lab technicians.) (Detail)

**I get the value of interprofessional teams especially in the realm of behavioral health and pharmacy, but NPs, PAs and CNMs are not adding specialized knowledge/ training. This is basically a way for programs to save money by hiring non-physicians instead of actually having more physician faculty.**
‐-----------------------

Honestly after reviewing all the changes, most of them seem pretty positive. They're actually adding some more specific OB care recommendations, expending a lot of Behavioral Health/SUD requirements, incorporating telehealth, etc. With the exception of the stuff above and in the OP, the changes seem either reasonable or even positive.

I encourage people to review the whole document, and in comments for the revisions focus primarily on the problematic ones in this thread.

I have come across a few FM programs that have NPs as faculty.

 

[deleted941485]

Truly embarrassing

I anticipate that more and more programs will have this.

 

[FrustratedFamDoc]

Surely these changes are to make sure that we as Family Docs continue to strive to put out a better trained product and It absolutely has nothing to do with money.

 

[Sushirolls]

The watering down of things must force the question, why even do FM?
Bring back the 1-2 year independently licensed GP.

 

[VA Hopeful Dr]

The watering down of things must force the question, why even do FM?
Bring back the 1-2 year independently licensed GP.

So they're possibly watering down training and then you still want to cut down the numbers of years? How does that many even the slightest sense?

Also, as I've pointed out numerous times before you aren't FP and so have no idea what our training or day-to-day practice is like in the first place so I'm not sure you're the best person to opine on this subject.

 

[Sushirolls]

Even though my view point is from a slightly outside vantage point, it doesn't necessarily mean that my comments on what I'm seeing lack merit.

ARNPs and PAs are rising in numbers, clinical duties, scope of practice, and according to this now academic duties training those who are supposed to be their clinical supervisors and superiors - family medicine residents / physicians. Anything in that sentence wrong?

Reimbursement rates by insurance companies are dropping the reduced rates given to ARNPs either voluntarily or by state based legislation. There are less and less insurance companies paying lower rates to midlevels. Pay parity means the profitability of hiring a midlevel is better, because you get more for their units of work, over shadowed when you pay them less. Pay parity also increases the viability of them entering private practice. Its not hard to find independent ARNP private practices. Anything in this observation wrong?

I'm simply saying, if the training is being watered down, and there is a rising tide of acceptance and utilization - in all clinical roles that FM are found - of ARNPs and PAs; it beckons this key questions: What then is the clinical difference? What then is the value of doing 3 years of residency when the minimal standard of state licensure 1-2 years depending, is already more formal training than an ARNP and PA? Why should a current intern who just got their independent license and starting to trudge into their PGY-II continue?

The only reason I can think is bureaucracy that the system is slightly stacked against them for employment jobs as they will often want BC/BE that is partly driven my med staff bylaws with local hospitals when privileges are obtained, and by a small portion of insurance companies. There are also possibly less medical liability insurance companies to pick from.

But when hospitals/health systems are pushing in more patients, providing less time for appointments, demanding more documentation, demanding more responsiveness to in basket messages, higher satisfaction scores and in essence expecting so much, much, much more per hour worked, and yet even paying less? Or now even requiring supervision of midlevels? The potential pros/cons of Big Box shop may be less than simply having a more relaxed less demanding cash practice as a GP, even if it means getting paid less. But when you dig through the weeds and details, the per hour rate may actually be much higher in a cash GP practice.

So how about you skip over critiquing me as an outsider, and counter point my observations and even my conclusions?

 

[VA Hopeful Dr]

So how about you skip over critiquing me as an outsider, and counter point my observations and even my conclusions?

Fine. Although I do this about 2 to 3 times a year scattered across this forum so a simple search might answer it for you.

But seeing as how I'm bored is all hell on covid isolation I've got the time.

It boils down to this: I remember where I was as a physician at the end of my second year of residency and at the end of my third. It was a huge difference. Intern year even more so as you would expect. I was an above average resident for what that's worth.

Just because under and untrained people are getting into the family medicine game doesn't mean we should decrease our training. Having read many posts in the psychiatric forum about solo psychiatric nurse practitioners, I would think the same would apply for y'all.

Also, I've supervised a number of nurse practitioners or worked with them over the years in various settings. Even the best of them was nowhere near as good as I am and while I think I'm a pretty good family doctor I'm nowhere near the best.

They're definitely are places that are increasing the number of mid-level providers compared to doctors. However, my experience has been that most of the time this is due to need more than anything else. Our office had both of our nurse practitioners leave recently and we were able to get a replacement to take over within 3 months of posting the job. Getting a new family doctor usually takes 12 to 18 months.

 

[Sushirolls]

You've seen the clinical differences in yourself with the current training.
I've seen the clinical differences as a Psychiatrist relative to midlevels, too.

But when credentialing and training entities are pushing to water down that very training that helped you to be the better, superior professional, how do you consolidate this new paradigm? If the newer batches of FM, don't get your clinical 'aha' moment between second and third year, should those 2nd and 3rd years even exist? Formally an intern trained physician already well exceeded an ARNP and PA, they are clinically fit to fill the role on the front lines like all the other mid levels in Big Box shops.

I'm willing to assume that incorporating more midlevel preceptors and trainers will be the blind leading the blind. So if the final product of FM residency trained physicians is closer to the goal post of an ARNP, then say the ol' guard FM of yesterday (you), should the 3 year residency even be encouraged?

What I'm trying to get at, is at what point as the whiskey been so watered down, that you stop calling it whiskey and label it water infused with whiskey?

If PGY-IIIs don't get your clinical 'aha' moment, should FM continue on anyways with lowered standards and lesser preceptors - if so, why?

 

[Sushirolls]

Conversely, if the psych side started to water down and infuse midlevels into the preceptor roles, and reduced clinical metrics drastically, I'd be advocating that PGY-III's half way through that year in Psych to jump ship, and open their own cash practices and advertise themselves as GPs emphasizing Psychiatry. There wouldn't be a point to continue on in the belly of the bureaucracy beast to then line up for a Big Box job in the traditional fashion.

 

[VA Hopeful Dr]

You've seen the clinical differences in yourself with the current training.
I've seen the clinical differences as a Psychiatrist relative to midlevels, too.

But when credentialing and training entities are pushing to water down that very training that helped you to be the better, superior professional, how do you consolidate this new paradigm? If the newer batches of FM, don't get your clinical 'aha' moment between second and third year, should those 2nd and 3rd years even exist? Formally an intern trained physician already well exceeded an ARNP and PA, they are clinically fit to fill the role on the front lines like all the other mid levels in Big Box shops.

I'm willing to assume that incorporating more midlevel preceptors and trainers will be the blind leading the blind. So if the final product of FM residency trained physicians is closer to the goal post of an ARNP, then say the ol' guard FM of yesterday (you), should the 3 year residency even be encouraged?

What I'm trying to get at, is at what point as the whiskey been so watered down, that you stop calling it whiskey and label it water infused with whiskey?

If PGY-IIIs don't get your clinical 'aha' moment, should FM continue on anyways with lowered standards and lesser preceptors - if so, why?

Its not about a clinical "ah-ha" moment. Its the simple fact that PGY-2s don't know as much medicine as PGY-3s. And interns know almost nothing about outpatient medicine even in my specialty which is the most outpatient-centric in all of medicine.

Even this watered down training is still much better than what midlevels get.

I suspect the midlevel incorporation has more to do with other specialties that we rotate with. The cardiology group at my old residency hospital (like many of them these days) has a huge number of midlevels for routine follow up stuff. I don't really agree with this change, but I bet its coming from stuff like that.

 

[VA Hopeful Dr]

Conversely, if the psych side started to water down and infuse midlevels into the preceptor roles, and reduced clinical metrics drastically, I'd be advocating that PGY-III's half way through that year in Psych to jump ship, and open their own cash practices and advertise themselves as GPs emphasizing Psychiatry. There wouldn't be a point to continue on in the belly of the bureaucracy beast to then line up for a Big Box job in the traditional fashion.

There's literally nothing legally stopping residents from doing that right now. I personally think that's a very bad idea, but it can be done.

 

[Splenda88]

I have said it multiple times and I was even shocked when the GME president of my institution said it.

You put a an average 'graduating' PGY2 (IM/FM) in the market place to work for a year, after that year, that individual will be better than most graduating PGY3. The ultimate goal of residency should be competency/safety, and after completing PGY2, I would wager that 90%+ IM/FM are safe/competent to practice on their own.

Again, med school curriculum should be 2-3 years of prereqs, 3 yrs of med school and 2-6 yrs residency. We should stop that madness. Otherwise, our profession won't survive.

 

[deleted941485]

I have said it multiple times and I was even shocked when the GME president of my institution said it.

You put a an average 'graduating' PGY2 (IM/FM) in the market place to work for a year, after that year, that individual will be better than most graduating PGY3. The ultimate goal of residency should be competency/safety, and after completing PGY2, I would wager that 90%+ IM/FM are safe/competent to practice on their own.

Again, med school curriculum should be 2-3 years of prereqs, 3 yrs of med school and 2-6 yrs residency. We should stop that madness. Otherwise, our profession won't survive.

I would wager this is likely the case of many specialties they can be safely practiced and competently practiced in less time than is currently required. FM may be the first to try this out.

 

[VA Hopeful Dr]

I would wager this is likely the case of many specialties they can be safely practiced and competently practiced in less time than is currently required. FM may be the first to try this out.

Sure, let's take the broadest specialty in medicine and shorten the training time for it. Makes sense.

 

[VA Hopeful Dr]

I have said it multiple times and I was even shocked when the GME president of my institution said it.

You put a an average 'graduating' PGY2 (IM/FM) in the market place to work for a year, after that year, that individual will be better than most graduating PGY3. The ultimate goal of residency should be competency/safety, and after completing PGY2, I would wager that 90%+ IM/FM are safe/competent to practice on their own.

Again, med school curriculum should be 2-3 years of prereqs, 3 yrs of med school and 2-6 yrs residency. We should stop that madness. Otherwise, our profession won't survive.

You're kidding right? FM training length hasn't changed since the field's inception. Not changing that will absolutely not be the cause of the field's downfall.

As I've said many many times to you, our training set up works great. Why change it? Other than student loan, and that's a problem that absolutely should be addressed but by cutting tuition not cutting length of residency.

 

[MatchGod]

Has anyone heard from program admins about the changes?

 

[Splenda88]

You're kidding right? FM training length hasn't changed since the field's inception. Not changing that will absolutely not be the cause of the field's downfall.

As I've said many many times to you, our training set up works great. Why change it? Other than student loan, and that's a problem that absolutely should be addressed but by cutting tuition not cutting length of residency.

The 2-yr model in Canada, which has the closest curriculum to us has worked.

If you complete PGY2 in FM/IM (8000+ hrs), and you are not safe to practice primary care, something is definitely wrong with your program. I am not sure a PGY3 year will fix your deficiencies

 

[KnuxNole]

I'm curious to see how the ACGME responds to the commentary from Program Directors. I submitted comments on behalf of our program in regards to concerns, and I am part of a listserv for PDs and the commentary is quite hot on certain issues. Part of me feels like with COVID and patient numbers declining some of this provides flexibility to avoid citations and probationary status. However, one of the things I've learned is that hospital admins listen to PDs when they push for certain experiences with the backing of residency requirements to ensure areas don't get cut.

 

[VA Hopeful Dr]

The 2-yr model in Canada, which has the closest curriculum to us has worked.

If you complete PGY2 in FM/IM (8000+ hrs), and you are not safe to practice primary care, something is definitely wrong with your program. I am not sure a PGY3 year will fix your deficiencies

Once again, our set up works perfectly well. Why should we make changes that almost be definition will make things worse?

 

[Splenda88]

Once again, our set up works perfectly well. Why should we make changes that almost be definition will make things worse?

Something might work perfectly well and yet still needs reform to increase efficiency.

Step2 CS worked really well, but did AMG really need it.

 

[deleted941485]

Something might work perfectly well and yet still needs reform to increase efficiency.

Step2 CS worked really well, but did AMG really need it.

Exactly.

I’m on a field where the training is unnecessarily long. They don’t even pretend like you need additional cases. You spend a “research year” where you just end up studying for a year for tests that don’t matter.

The problem is widespread…all but mandatory fellowships to cover stuff you should have seen enough of in residency. “Research fellowships” which are. Are basically data entry jobs

I cannot help but think of all the wasted hours days months years when a person could have been seeing patients but instead is too busy padding their resume with garbage papers, taking tests memorizing irrelevant info, and kissing ass to get recommendations for fellowships they probably don’t even need.

 

[Splenda88]

Exactly.

I’m on a field where the training is unnecessarily long. They don’t even pretend like you need additional cases. You spend a “research year” where you just end up studying for a year for tests that don’t matter.

The problem is widespread…all but mandatory fellowships to cover stuff you should have seen enough of in residency. “Research fellowships” which are. Are basically data entry jobs

I cannot help but think of all the wasted hours days months years when a person could have been seeing patients but instead is too busy padding their resume with garbage papers, taking tests memorizing irrelevant info, and kissing ass to get recommendations for fellowships they probably don’t even need.

And many attendings are pretending a lot of these things are necessary.

A lot of these FMG did 5 yrs medicine in the homeland and do residency here. Studies have demonstrated that we are no better than them in term of outcomes.

 

[VA Hopeful Dr]

Something might work perfectly well and yet still needs reform to increase efficiency.

Step2 CS worked really well, but did AMG really need it.

Not even close. CS was trying to address a need that wasn't there. It wasn't needed it the first place. It's not like that test was always part of medical licensing from the beginning. They took a test that we gave to foreign graduates to make sure that they knew English well enough and had a bare minimum of social skills and said "hey, we should make every single medical student take this" which was stupid.

 

[VA Hopeful Dr]

Exactly.

I’m on a field where the training is unnecessarily long. They don’t even pretend like you need additional cases. You spend a “research year” where you just end up studying for a year for tests that don’t matter.

The problem is widespread…all but mandatory fellowships to cover stuff you should have seen enough of in residency. “Research fellowships” which are. Are basically data entry jobs

I cannot help but think of all the wasted hours days months years when a person could have been seeing patients but instead is too busy padding their resume with garbage papers, taking tests memorizing irrelevant info, and kissing ass to get recommendations for fellowships they probably don’t even need.

Honestly one of my large draws to family medicine was that we are the least research oriented field in all of medicine. My "research project" to graduate residency was a chart audit. It took me less than 2 days of solid effort.

My personal opinion is that if students want to do research the opportunities and the time to do it should absolutely be there and should be encouraged but it should not be a requirement for the vast majority of medicine.

And yes don't get me started on inventing new fellowships for things that used to be considered bread and butter of the specialty. Looking at you pediatric hospitalist fellowship.

 

[Ironheme]

It definitely seems like big changes. I am skeptical of some changes (less peds, less/no gyn?). However, they are proposing increasing the amount of electives, and I agree with some of the above posters that programs aren't going to lower their standards of training simply because the ACGME requirements are lower.

If you're a resident and you want your training of one month of ortho/MSK - you can do that with the proposed extra elective months. I see it as an opportunity to tailor more of your training to what you'd like. Sure, there going to be some residents that use these lowered requirements + more electives to fly under the radar and become refer-ologists. But they were likely going to do that anyways before these proposed changes.

I'd like to think most residents are adult learners that will seek out opportunities to improve their areas of weakness. Most of them understand that they need to do this for the benefit of patient care in the future.

 

[hallowmann]

It definitely seems like big changes. I am skeptical of some changes (less peds, less/no gyn?). However, they are proposing increasing the amount of electives, and I agree with some of the above posters that programs aren't going to lower their standards of training simply because the ACGME requirements are lower.

If you're a resident and you want your training of one month of ortho/MSK - you can do that with the proposed extra elective months. I see it as an opportunity to tailor more of your training to what you'd like. Sure, there going to be some residents that use these lowered requirements + more electives to fly under the radar and become refer-ologists. But they were likely going to do that anyways before these proposed changes.

I'd like to think most residents are adult learners that will seek out opportunities to improve their areas of weakness. Most of them understand that they need to do this for the benefit of patient care in the future.

I honestly don't see the issue as one of residents becoming lazy. The bigger issue is lackluster programs (especially the for-profit ones that have proliferated lately) offering the bare minimum. It doesn't matter how many electives in gyn you do if you are being staffed by an FNP in a "women's clinic" that refers everything but Nexplanons to the private OBs that don't take residents. It doesn't matter how many Peds electives you do if your institution no longer has a Peds hospital and Peds service and all you are doing is well child checks staffing with the Peds NP. That's the bigger threat I see and more likely to create referologists.

It's hard to continually explain why primary care requires physicians when training is continually whittled away and we are "taught" by midlevels.

Some of you may be far out of academia, but over these years I've seen big shifts in our system, and it's always in the name of saving money and advertised as "better access to care". The patients I send to specialists all are seen by midlevels, residents lose procedures and training opportunities to NP "residents", our continuity patients are unable to get in to see us not due to lack of clinic time, but rather due to being filled with the panels of ever-increasing midlevels because expansion has been focused on NPPs with starting salary for physicians, which was low to start with, stagnating for at least the last 5 yrs. I can't shake the idea that at least some of these changes will be used to the detriment of residents and the benefit of hospitals.

 

[FrustratedFamDoc]

Not even close. CS was trying to address a need that wasn't there. It wasn't needed it the first place. It's not like that test was always part of medical licensing from the beginning. They took a test that we gave to foreign graduates to make sure that they knew English well enough and had a bare minimum of social skills and said "hey, we should make every single medical student take this" which was stupid.

I try so hard to not get jaded the longer I practice, but extortion runs so rampant in our profession. Just imagine the revenue generated every year from CS? Think it's ever going away? Why do DEA and state licenses have to cost hundreds of $$ every few years? Why not $50 a piece. Why does the AAFP have a mandatory 25 live credit hours requirement (not this cycle, thankfully)? Residency expansion is cheap labor to hospitals.

The idea for midlevel supervision for residents didn't just fall out of the sky. It's just another example of docs selling out their own for whatever reason. It's been going on for quite some time and won't stop until all primary care education is considered the same.

 

[VA Hopeful Dr]

I try so hard to not get jaded the longer I practice, but extortion runs so rampant in our profession. Just imagine the revenue generated every year from CS? Think it's ever going away? Why do DEA and state licenses have to cost hundreds of $$ every few years? Why not $50 a piece. Why does the AAFP have a mandatory 25 live credit hours requirement (not this cycle, thankfully)? Residency expansion is cheap labor to hospitals.

The idea for midlevel supervision for residents didn't just fall out of the sky. It's just another example of docs selling out their own for whatever reason. It's been going on for quite some time and won't stop until all primary care education is considered the same.

Work to relaunch USMLE Step 2 CS discontinued | USMLE

www.usmle.org

After reviewing current and anticipated progress with the exam and in consideration of the rapidly evolving medical education, practice and technology landscapes, we have decided to discontinue Step 2 CS. We have no plans to bring back Step 2 CS

So yes, I do think CS is going away. I will be curious what its replaced by admittedly.

My understanding is that DEA and license fees are the costs to pay everyone who in involved in that process. I can't speak to everywhere, but my medical board isn't getting rich off license fees nor is our state level controlled substance program.

I think the AAFP thing is a remnant from when pretty much all CME was live. I'm glad to see it gone and hope it stays that way.

 

[Splenda88]

Work to relaunch USMLE Step 2 CS discontinued | USMLE

www.usmle.org

So yes, I do think CS is going away. I will be curious what its replaced by admittedly.

My understanding is that DEA and license fees are the costs to pay everyone who in involved in that process. I can't speak to everywhere, but my medical board isn't getting rich off license fees nor is our state level controlled substance program.

I think the AAFP thing is a remnant from when pretty much all CME was live. I'm glad to see it gone and hope it stays that way.

They will find something to replace it with to make their $$$.

 

[VenusinFurs]

The 2-yr model in Canada, which has the closest curriculum to us has worked.

If you complete PGY2 in FM/IM (8000+ hrs), and you are not safe to practice primary care, something is definitely wrong with your program. I am not sure a PGY3 year will fix your deficiencies

I think pgy 3 was useful mainly because I actually got to learn a little extra on my electives and primarily for the teaching experiences and for me personally I needed that year to mature but that isn’t true for everyone

 

[Splenda88]

I think pgy 3 was useful mainly because I actually got to learn a little extra on my electives and primarily for the teaching experiences and for me personally I needed that year to mature but that isn’t true for everyone

You could have used that year as an attending to mature..

I like that most med students/residents buy into academia BS.

People were practicing as GP (1-yr post grad) 25+ yrs ago. I know someone will come here and say there is a lot more to lear nowadays. I guess 25 yrs from now, there will be FM PGY6 because there will be a lot more to learn than today.

 

[VA Hopeful Dr]

You could have used that year as an attending to mature..

I like that most med students/residents buy into academia BS.

People were practicing as GP (1-yr post grad) 25+ yrs ago. I know someone will come here and say there is a lot more to lear nowadays. I guess 25 yrs from now, there will be FM PGY6 because there will be a lot more to learn than today.

I like how even us attendings who have been out for almost a decade and think that the 3rd year has value always get overlooked.

I like how we have a system that has worked well for over 50 years yet clearly is a waste of time.

I like how people talk about GPs but 99% of the people talking them up have probably never actually met one who is practicing regular primary care.

I like how no one seems to remember that awhile back there was lots of talk about adding a 4th year to FM residency but no one outside of a handful of PDs thought it was a good idea and it got dropped and hasn't been brought up again since.

But what I like best is people who aren't FPs and haven't been through FM residency telling us who are/have what we should be doing.

 

[Splenda88]

I like how even us attendings who have been out for almost a decade and think that the 3rd year has value always get overlooked.

I like how we have a system that has worked well for over 50 years yet clearly is a waste of time.

I like how people talk about GPs but 99% of the people talking them up have probably never actually met one who is practicing regular primary care.

I like how no one seems to remember that awhile back there was lots of talk about adding a 4th year to FM residency but no one outside of a handful of PDs thought it was a good idea and it got dropped and hasn't been brought up again since.

But what I like best is people who aren't FPs and haven't been through FM residency telling us who are/have what we should be doing.

If you think 90%+ of FM residents won't be safe to practice medicine after PGY2, I might agree with you. I know you know that is not the case.

Not claiming that I have been thru FM residency; however, I rotated with FM residents both outpatient/inpatient. Therefore, I know a little about the specialty. And what I said, was said by the GME president of the IM university program I did my IM residency and she has been at that job for 15+ years. Again she said something of that sort that 90%+ of FM/IM/Peds residents are safe to practice medicine after PGY2.

It would be interesting to take 2 average IM or FM residents. Make one of them work as attending after PGY2 for 1 year and let the other finish PGY3; and I wonder which one of them would come out more competent (without doing no harm).

 

[VA Hopeful Dr]

If you think 90%+ of FM residents won't be safe to practice medicine after PGY2, I might agree with you. I know you know that is not the case.

Not claiming that I have been thru FM residency; however, I rotated with FM residents both outpatient/inpatient. Therefore, I know a little about the specialty. And what I said, was said by the GME president of the IM university program I did my IM residency and she has been at that job for 15+ years. Again she said something of that sort that 90%+ of FM/IM/Peds residents are safe to practice medicine after PGY2.

It would be interesting to take 2 average IM or FM residents. Make one of them work as attending after PGY2 for 1 year and let the other finish PGY3; and I wonder which one of them would come out more competent (without doing no harm).

Well if rotating with FM residents is all it takes, I should start pontificating about general surgery, OB/GYN, and pediatric residency programs. Heck I've got you beat because I actually rotated in those specialties not just with their residents.

Also, an IM PD isn't an FP and didn't go through FM residency so I don't really care what she has to say either. Things might be different now but most places I'm familiar with the FM residents did inpatient rotations with the IM residents and that was it. So if we're being generous, that PD could say that 90% of residents were safe to practice inpatient medicine. She wouldn't be familiar with their peds, ob/gyn, or outpatient abilities. Given how in most programs the first 2 years are very heavy in inpatient her opinion on that area could very well be true. Outpatient and gyn are much more weighted toward 3rd year. For example, I graduated residency with around 2200 outpatient encounters. At the start of 3rd year, I had around 1000. Its also worth noted that to graduate FM residency you have to have 1650 outpatient encounters which is very tricky to do in just 2 years along with everything else we have to do.

 

[Splenda88]

Well if rotating with FM residents is all it takes, I should start pontificating about general surgery, OB/GYN, and pediatric residency programs. Heck I've got you beat because I actually rotated in those specialties not just with their residents.

Also, an IM PD isn't an FP and didn't go through FM residency so I don't really care what she has to say either. Things might be different now but most places I'm familiar with the FM residents did inpatient rotations with the IM residents and that was it. So if we're being generous, that PD could say that 90% of residents were safe to practice inpatient medicine. She wouldn't be familiar with their peds, ob/gyn, or outpatient abilities. Given how in most programs the first 2 years are very heavy in inpatient her opinion on that area could very well be true. Outpatient and gyn are much more weighted toward 3rd year. For example, I graduated residency with around 2200 outpatient encounters. At the start of 3rd year, I had around 1000. Its also worth noted that to graduate FM residency you have to have 1650 outpatient encounters which is very tricky to do in just 2 years along with everything else we have to do.

Programs can be restructured. Requirements can be changed. During the peaked of covid, a lot of these requirements were changed.

I wonder if the AAFP has data about % of FM docs who truly see peds/Obgyn patients. Not talking about treating otitis media, PIH, and doing PAP etc..., which even most IM docs also do.

 

[Lurts]

My third year of FM residency consisted of 4 months of inpatient medicine and 8 months split amongst required and elective outpatient rotations.

Had I gone straight into independent practice after PGY2, I do think I could have competently practiced what I had already learned.

I fail to see how I could have similarly learned the nuances I picked up on a month rotation of Derm, ENT, Ophtho, Ortho, Urology, etc by just going straight into practice.

The answer should never be less training in my opinion. I’d be more likely to advocate for a PGY4 year in FM than I would dropping the third year.