Advice on ACGME and my problem

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WannaSwitchBack

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Hello,

I am a pgy4 and I recently started a C& A fellowship here @ my program which has the ability to take residents in their fourth year. I decided to go into child late in the game, after the match left an open spot in the fellowship here @ my program. All I had to do was fill out some paperwork ( the app) and move my stuff to a different building after they accepted me ( I was a shoe- in as I was a qualified internal applicant and they did not fill). I can already tell that I have made a mistake and I want to get back into the general program and graduate next year. The thought of an extra year is really getting to me, as all I wanted to do was treat adolescents plus adults, not the younger kids.

Is there any way to get back into the general program? Anyone know of residents who have done this? Am I screwed? I want to leave this town and get back to treating adults. Anyone know of residents who have been in similar situations who have been able to switch back to gen adult? It's the same sponsoring institution here so I am thinking I could continue with child for a few months ( electives) then go back next door and finish up my general training ( it's all electives so the requirements are not an issue).

THANKS
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In most programs, if you finish your 1st year in child, you are really completing your PGY4 year. So, you should be board eligible for general psychiatry and be able to graduate after this year, regardless of whether or not you continue in the fellowship. You'll have to check with your program to make sure you've completed all your requirements. But if you were able to transfer out of your adult training, this shouldn't be a problem from a graduation standpoint. After my 1st CA year, I went to graduation with my former adult co-residents and if I wanted, I could stop training now and be able to be board certified in general psych. Obviously, you couldn't do child if you did this.

Regarding returning to adult, you'll have to speak to your program about this. Sounds like that will really be up to them and their budget.
 
You likely will not be able to get out of the child program. When you get into a program, they must have you down for hours to be clinically served, and if you don't serve them, the program, and the place where you'd end up providing services are screwed. It could literally end up with the place not being able to provide services they must legally provide.

E.g. if you're set up to work at an ER, you just can't walk out of it. Arrangements were already made for you to take up a portion of the work so that the services could still be provided.

I know of a particular resident while I was in training, and he was narcissistic and egocentric. The guy didn't want to do a rotation and decided to just not show up.

Let's just say that when the program found out, (edit: he) was asked to not show up ever again...for anything.

Years later, while working as an ice cream man (I'm not kidding), and having lost a lot of money on a quixotic dream that he'd make it big in real estate (he was fired right before the real estate crash) and finally figuring out he'd be better off as a doctor, no program was willing to take him, at least as far as I knew for years, when they found out he literally abandoned his responsibilites as a resident.

I'm not implying that I believe you would do the same, but just mentioning the above to give you an idea of what's going on. You really need to address this with the PD, or just keep your mouth shut and finish the program. It's possible you might end up liking what you are doing and you're just having some cold feet.
 
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WannaSwitchBack said:
Hello,

I am a pgy4 and I recently started a C& A fellowship here @ my program which has the ability to take residents in their fourth year. I decided to go into child late in the game, after the match left an open spot in the fellowship here @ my program. All I had to do was fill out some paperwork ( the app) and move my stuff to a different building after they accepted me ( I was a shoe- in as I was a qualified internal applicant and they did not fill). I can already tell that I have made a mistake and I want to get back into the general program and graduate next year. The thought of an extra year is really getting to me, as all I wanted to do was treat adolescents plus adults, not the younger kids.

Is there any way to get back into the general program? Anyone know of residents who have done this? Am I screwed? I want to leave this town and get back to treating adults. Anyone know of residents who have been in similar situations who have been able to switch back to gen adult? It's the same sponsoring institution here so I am thinking I could continue with child for a few months ( electives) then go back next door and finish up my general training ( it's all electives so the requirements are not an issue).

THANKS
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Could you give us a little more detail about what you don't like? I've done a couple of C&A rotations and found it to be mostly older kids. I'd say 90% were 13+, with a few younger ones thrown in.

What ages and problems are you seeing the most of?

I am also more interested in adolescent psych than little kids, but it seems that to do adolescent you have to do child too. That being said, I'm willing to tough out the 2 years of all age kiddies in order to get where I want to be.

I'd say tough it out, then you can set your ages when you have your own place in a couple of years...
 
You will need to talk to both the adult and CAP PDs. In addition to the clinical coverage and professionalism issues mentioned by others, there is also the education issue. The PDs will need to determine that if you do transfer back whether they can cover all of your educational needs. In addition they will have to communicate with the ABPN and get their approval. ABPN does not usually allow for split years. They will need to sign off on any split year because if they do not, then you risk to be in the situation where you have finished 4 years of training but the Board does not consider you board eligible.
 
You likely will not be able to get out of the child program.
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Clarifying what I wrote before. You will likely not be able to get out for this year. They might be able to get out of the fellowship as a general psychiatrist by having your fellowship year count as your PGY IV for general residency.

I advise you to talk to the PD. Who knows? You might be able to get out and not do the fellowship year.
 
Also consider how the work load is spread out. In my fellowship, it would have been exceedingly hard on everyone, but especially the other first year fellows, if someone had left in the first year. For that reason, I highly doubt that the child and adult program directors would have allowed anyone to transfer, and if they had, the fellow would not have left on good terms with the rest of the fellows. As whopper said, the work has been assigned and they are counting on you to be there to do it. It's probably a very different issue if you want to leave at the end of the PGY-4 year.
 
alina_s said:
Also consider how the work load is spread out. In my fellowship, it would have been exceedingly hard on everyone, but especially the other first year fellows, if someone had left in the first year. For that reason, I highly doubt that the child and adult program directors would have allowed anyone to transfer, and if they had, the fellow would not have left on good terms with the rest of the fellows. As whopper said, the work has been assigned and they are counting on you to be there to do it. It's probably a very different issue if you want to leave at the end of the PGY-4 year.
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Agree. If you leave the child fellowship, this could cause major problems for your fellow fellows (no pun intended :D) and the child program. Unless you are certain that this wouldn't be the case, you might want to be very careful about asking to switch back. My suggestion would be to complete your year in child and then leave, assuming this will fullfil your graduation requirements.
 
This could go any number of ways, and we're all just speculating. You really should just sit down with your child program director, explain your regrets, and ask what your options would be. (There is minimal risk to this. The worst thing that happens is that you have to finish your fellowship, which is the same position you are in right now.) If your service lines aren't so fellow dependent, it might not be a big deal. If they are, you might really alienate yourself with people and harm your job prospects if you demanded to leave the fellowship. You might be able to graduate at the end of the year, you might not. But these answers are probably very different at different institutions.
 
The video was more appropriate than you know, cause that was the exact franchise he worked for. People used to say the Mr. Softee song was his theme.

As bad as this guy sounded, I actually liked him. He had his issues but he was honest about them. There were other residents or attendings I thought were evil, but smart enough to keep their mouths shut when doing their dirty work. The guy screwed up, but his brutal honesty at times was needed and refreshing.

(Mentioned this before, but I know of a PD at a forensic fellowship at a namebrand place that has a rep for saying anything so long as it gets his client out of trouble).

I call him egocentric because he did his actions without thinking of the consequences as if he had an invulnerability streak. While the program I was in was IMHO too lax, he was willing to take it as far as he could. He told me of his plan to not show up and I tried to talk him out of it. Trust me, I've seen some programs too lax, most however I believe are too strict, but you never don't show up. When that happens, people could literally end up in jail. The most lax PD will not let that pass when he/she could be the one pointed out as legally negligent. Wit hen people don't show up, the problem will go beyond the program and other depts such as the GME will be notified.

It's easy to cover a mistake when a few people are in on it, but when too many people see it, it's out in the open and cannot be overlooked.
 
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I appreciate all of your replies so much. It's nice to have this board to use while brainstorming. I have not spoken to my PD because I am not usually the type to simply announce my thoughts to the world. So, this is really helpful.

Whopper- the situation in this program is such that the sponsoring institution is the same regardless of which program I am in, thus I am lucky in that there will not be an external institution expecting me to show up and work ( and have money between the institutions be an issue).

It is true that I really enjoy inpatient and I am currently outpatient, which is one of the reasons I am not saying anything out loud yet. I want to work with adolescents, actually ages 14 and up. Not particularly motivated to work with younger kids. Also, I am interested in working in somewhat underserved areas. Thus I am really wondering if the extra year is worth it. I have a huge debt burden, am slightly older than the average resident, and really just thought to myself " I can suck up the extra year just to be get the credentials". Now I am thinking- why bother if all I want to treat are older kids? Not sure the C&A credentials are still needed in the underserved area I am aiming to return to. Also, my significant other hates it here and would be here an additional year thanks to my decision.

I really enjoy general adult psych and even geri ( which, I rotated through at the end of my third year - after I had applied to child, thus my exposure to geri was nil at the time of the application to C & A). I would switch back to the general program in order to have a few months of geri electives prior to graduation. So.... these are some of my thoughts.

I am headed over to the ACGME page to see what it has to say about the ability to graduate at the end of pgy4. I don't think I am anywhere near the ice cream truck at this point. The call schedule here really would not even be effected ( we have weekend pager call only, and I was an add- on to their schedule, they were not expecting me from last fall until this spring as I joined in the spring, so it's not that big an issue). Thanks so much for your replies!
 
Good luck finding the answer with the ACGME. I had some graduation questions for a totally unrelated issue and had a very hard time getting any specific information from them. My advice is that you really need to speak to someone within your program such as the residency coordination who fully understands the graduation requirements and your program.

Also, if you think you want to work on an inpatient adolescent unit (those units do exist), you might want to consider completing the fellowship. The fellowship will be very beneficial in helping you be a good adolescent psychiatrist and will give you insights into that population that you're just not going to get in working with adults. You really need to have a developmental perspective to work with teenagers, even though you might not work with children. Also, an inpatient adolescent unit will always look for a board certified CA psychiatrist before thinking about hiring someone without that fellowship.

Good luck!
 
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i'm going to give it some time. I will come back with an update when I have something, if anything to report. I am just so tired of being a resident- sometimes I wonder if that is what's causing me to want out now. Seeing my pgy4 friends who are getting ready to move on, missing treating adults, hating IEP's and ADHD. Ouch. Will keep you posted in case anyone ever runs a search on the board for this topic. BillyPilgrim summed it up- I really just need to talk to my PD- but understandably I am not ready for such a big move right now.

Thanks everyone!
 
I've known a person to bail on their child fellowship to return to their original program. They communicated with all parties involved, but the returning program gave the resident call for the rest of the year... I don't know at what point this person bailed.
 
I know someone who bailed on their child program after year 1 to go work in general psych. Got a very good job offer in their hometown and "had to take it." Program was very understanding about the whole thing. I was present (on rotation) at the meeting where the fellow broke the news of her final decision, although the PD knew about it already, and was very gracious...so it is possible.

Personally, I don't think it could hurt to talk to your PD, as long as they're relatively understanding. You don't have to say "I want to leave, this sucks," but I don't see anything wrong with saying, "these are the concerns I have." The PD, if they have any experience at all, has probably dealt with people with similar feelings (which I think is more common than not) and might be able to help, either through program structuring or just telling you that everyone feels that way at first and that it gets better.
 
I went from resident to attending to fellow to attending.

The first few months I felt somewhat bugged. There's an attitude attendings have of wanting obedience from those under them. I was fine with that when the attendings knew more than I did. As a fellow, I felt I knew more than most of the attendings. I don't say that as some type of achievement because I see so many attendings doing things a good PGY I wouldn't do. Just that a PGY I doesn't know their attending blows until they reach the later years. While my PD knows far more in several areas than I do, and in totality is much more of a psychiatrist than I am, I did think I was better than him in certain clinical aspects. So on a few occasions, if we disagreed, it was harder for me to accept being in the fellow position.

And the odd thing was is that my former fellowship PD was a heck of a teacher, good man, and one of the best doctors in the country. He was the type of guy that'd listen to me when we disagreed. I pretty much was in awe of him. Half the time I caught him in the middle of doing something when I knocked on his door, he was conferring with some of the top doctors in the country, writing a letter to the editor of a top journal and seeing the letter get published, or reviewing a journal article for publication because he's an editor on several of the top journals.

I shutter to think what it would've been like to have been an attending and then be a fellow in a program where the PD was a totalitarian and someone I didn't respect. Ouch that would've been bad.
 
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Whopper, it's interesting that you write what you do, because it somewhat describes how I am feeling as a fellow at this point. I just can't act obsequious and I can't act like I don't know what I'm doing at this point. When attednings expect that kissy kiss attitude, I cringe inside. I just want to treat people the way I would want to be treated, not like they are made of gold. I moonlight on my own now and I know I have a lot to learn, but I am perfectly capable when moonlighting. I have so much to keep reading about and learning, but at this point I don't see many of my attendings inspiring me. Except, perhaps, in what not to do. Ouch.

My PD is a different story- definitely an inspiration. The bad news is that this individual is about to resign as PD. The new one coming in happens to be an individual that I simply don't respect. This is only adding fuel to my thougts of switching back to general and getting out of here.

I really appreciate hearing from Sneezing and Digitlnoize also as the anecdotes
give me hope. Still thinking it over...
 
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Several attendings are the Wizard of Oz. They're actually some pathetic guy, and by the time you reach PGY 3 or 4 you realize you're likely on the road to be better than them if not already if you actually love what you're doing and read up on things like journals because you actually enjoy it. Many medstudents and residents can sniff out those among them that don't give a damn about their fellow man but will graduate to become doctors. Does anyone here honestly believe that none of those types won't enter a training program? Some attendings I know specifically became an attending in a residency program with the specific intent of having residents do all their work for them so they could be lazy. It's one of those things where they don't tell these to the people in the lower ranks.

I write this because fellows are kinda in the cusp of this process. They know what I'm talking about. They know that they can tell they're going to be better than some of their teachers in residency but are still green in some respects. The good thing about fellowship is many of the instructors know they're getting people that could've stopped their training but still want to continue. I can't say every fellowship is a good one, but you are in a better position to get very individualized training at a hyper specialized level.

I noticed the good attendings are the ones that love what they do and try to learn more and more even after training. The bad ones don't care for the job and are no better at what they do even after doing it for years.

The bad news is that this individual is about to resign as PD.
Click to expand...

A thing at least in forensic fellowship is the training is highly dependent on the PD. Most forensic fellowships only have a few people, maybe up to 3-4. If the fellowship PD changes, the entire program being vastly different.
 
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whopper said:
Several attendings are the Wizard of Oz. They're actually some pathetic guy, and by the time you reach PGY 3 or 4 you realize you're likely on the road to be better than them if not already if you actually love what you're doing and read up on things like journals because you actually enjoy it. Many medstudents and residents can sniff out those among them that don't give a damn about their fellow man but will graduate to become doctors. Does anyone here honestly believe that none of those types won't enter a training program? Some attendings I know specifically became an attending in a residency program with the specific intent of having residents do all their work for them so they could be lazy. It's one of those things where they don't tell these to the people in the lower ranks.

I write this because fellows are kinda in the cusp of this process. They know what I'm talking about. They know that they can tell they're going to be better than some of their teachers in residency but are still green in some respects. The good thing about fellowship is many of the instructors know they're getting people that could've stopped their training but still want to continue. I can't say every fellowship is a good one, but you are in a better position to get very individualized training at a hyper specialized level.
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:thumbup:

I totally know what you mean. Sigh.
 
I admire that you are following your passion
 
Thanks psychgeek. I am going to wait until a couple more weeks have passed. Think that the more proper thing to do, if I ask to return (literally across the hall), would be to offer to finish up the term through the holidays as a fellow
( the call schedule, although it is a very light call schedule- home pager call for consults on a service that calls very little-has been made through Thanksgiving already- so I would offer to leave myself on that call schedule). I would request to return in January and take other pgy4 electives prior to graduation. Still thinking it over, so I will return to this board after I have decided and let you know what transpires.
 
psychattending said:
You will need to talk to both the adult and CAP PDs. In addition to the clinical coverage and professionalism issues mentioned by others, there is also the education issue. The PDs will need to determine that if you do transfer back whether they can cover all of your educational needs. In addition they will have to communicate with the ABPN and get their approval. ABPN does not usually allow for split years. They will need to sign off on any split year because if they do not, then you risk to be in the situation where you have finished 4 years of training but the Board does not consider you board eligible.
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Psychattending,
My plan at this time, if I ask, is to request that the months I have spent in C&A be counted as elective months, not C&A months. The pgy4 year here is virtually 100% elective. So, would that not make the question of "split years" a moot point?
 
I spoke with my PD earlier this week. Just expained my regrets and concerns. I was assured that the year I am in currently can in fact count as my pgy4 year, so essentially there is no rush to decide.

I did not ask to return to pgy4 electives other than child. I will wait and consider doing that at a later time in the year. Fact is that I am going to finish the first half of this year as it is regardless, so if I want to request doing electives later in the year, I still have time to request that. So many of the previous posters were correct- I will be BE for general at the end of this year. Don't have to sign a contract in the spring unless I have a change of heart. Thanks for all of your replies. Much appreciated!
 
WannaSwitchBack said:
Psychattending,
My plan at this time, if I ask, is to request that the months I have spent in C&A be counted as elective months, not C&A months. The pgy4 year here is virtually 100% elective. So, would that not make the question of "split years" a moot point?
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WannaSwitchBack,

Sorry for the tardy reply but I was off doing the vacation thing. It's not an issue of being able to count something from CAP training for your adult requirements. Split year refers to splitting one academic year between two different programs (even two adult programs). ABPN (not ACGME) apparently looks down on such a thing since it sees training as occurring in 1 year increments. It is not an insurmountable hurdle but it is an issue that you should address so it does not come back to haunt you. It would probably just take letters from your two programs laying out how they are going to coordinate your training between them for the year. ABPN would then write back a letter saying that they approve of the plan and will count your combined time for Board eligibility. You would want to keep a copy of that letter just in case the administration changes at ABPN and they forget what they had previously told you and your programs.

Contacting ABPN about a split year is only important if you officially transfer your training from the CAP program to the adult program mid-year. If you do your entire PGY4 year in CAP, there is no need to contact ABPN because there is no split year.
 
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psychattending said:
WannaSwitchBack,

Sorry for the tardy reply but I was off doing the vacation thing. It's not an issue of being able to count something from CAP training for your adult requirements. Split year refers to splitting one academic year between two different programs (even two adult programs). ABPN (not ACGME) apparently looks down on such a thing since it sees training as occurring in 1 year increments. It is not an insurmountable hurdle but it is an issue that you should address so it does not come back to haunt you. It would probably just take letters from your two programs laying out how they are going to coordinate your training between them for the year. ABPN would then write back a letter saying that they approve of the plan and will count your combined time for Board eligibility. You would want to keep a copy of that letter just in case the administration changes at ABPN and they forget what they had previously told you and your programs.
Contacting ABPN about a split year is only important if you officially transfer your training from the CAP program to the adult program mid-year. If you do your entire PGY4 year in CAP, there is no need to contact ABPN because there is no split year.
Click to expand...

Thanks psychattending. This is extremely helpful, as I have not officially
asked to switch back over to general residency, I definitely won't bother to now. I basically think that if I were to finish the first year of fellowship and also obtain the certification in adolescent psych (which, unfortunately I did not find out existed until after joining the 2 year program), that should be enough for what I want to do in the future (treat adults and a few adolescents, possibly do some inpatient adolescent work). So, I feel good about the decision and also relieved that my PD knows I am not returning and also understands. Thanks again!
 
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