Are FM residents struggling to get clinic numbers?

[deleted979844]

Hey, FM PGY1 here. As the title suggests, I was really shocked when I started residency and all of our residents drastically behind on their clinic numbers. The environment in clinic has become toxic because there isn’t enough patients to for everyone to reach their numbers. I keep getting told it’s because of COVID by my seniors, but the people I’ve talked to in other programs seem to be over the COVID hump by now.... It just seems like this has been going on long enough for the program to have started making arrangements to fix the issue?

I understand that ACGME came out with some statement that says that programs should be allowed to graduate residents based off competence and not numbers, but it still annoys me that my training is being short-changed like that. I’m also starting to feel like the onus to fix the issue is being thrown on the residents. I wasn’t anticipating having to hand out flyers on the street to attract patients when I started residency.

I really hate being the squeaky wheel. But I’ve spoken to my seniors and faculty advisors and I feel like their response has been equivalent to “sucks for you”. I’m feeling edged into a corner. I’m willing to spend more time in clinic to compensate but there are literally no patients to be seen. I’m not sure what to do anymore or what attitude to take. Should I just leave it be or try to do something? The faculty tell me not to worry and then scold me that I’ve seen close to zero clinic patients in 4 months. Any outside perspective or wisdom would be appreciated.

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[smq123]

Hey, FM PGY1 here. As the title suggests, I was really shocked when I started residency and all of our residents drastically behind on their clinic numbers. The environment in clinic has become toxic because there isn’t enough patients to for everyone to reach their numbers. I keep getting told it’s because of COVID by my seniors, but the people I’ve talked to in other programs seem to be over the COVID hump by now.... It just seems like this has been going on long enough for the program to have started making arrangements to fix the issue?

I understand that ACGME came out with some statement that says that programs should be allowed to graduate residents based off competence and not numbers, but it still annoys me that my training is being short-changed like that. I’m also starting to feel like the onus to fix the issue is being thrown on the residents. I wasn’t anticipating having to hand out flyers on the street to attract patients when I started residency.

I really hate being the squeaky wheel. But I’ve spoken to my seniors and faculty advisors and I feel like their response has been equivalent to “sucks for you”. I’m feeling edged into a corner. I’m willing to spend more time in clinic to compensate but there are literally no patients to be seen. I’m not sure what to do anymore or what attitude to take. Should I just leave it be or try to do something? The faculty tell me not to worry and then scold me that I’ve seen close to zero clinic patients in 4 months. Any outside perspective or wisdom would be appreciated.

Is your clinic doing telehealth?

 

[deleted979844]

Is your clinic doing telehealth?

From what I understand we do have telehealth but it does not count towards our encounters, or at least I’ve been told. As such, residents haven’t been using it often.

 

[smq123]

From what I understand we do have telehealth but it does not count towards our encounters, or at least I’ve been told. As such, residents haven’t been using it often.

What's the justification for not counting telehealth encounters? That seems silly.

It's also a disservice to your patients. Patients come to residency clinics because they are one of the few outpatient places that reliably take Medicaid and uninsured patients. By not offering telehealth to patients now, you are either a) depriving them of timely medical care, or b) depriving them of medical care at all.

Does your residency clinic not see OB patients either? They're some of the few patients who absolutely need to be seen on a regular basis, and they cannot always be seen by telehealth.

 

[smq123]

If your residency attendings or program directors cannot think of ways to boost clinic numbers, that's a whole other red flag in and of itself, though. There are a ton of ways to "drum up business" and increase volume.

- Do you have a running list of uncontrolled diabetics? How about diabetics who have not had an A1C in 6 months?
- Do you have a list of patients who are delinquent on paps?
- Do you have a list of patients whose last measured blood pressure was over 140/90?
- Do you have a list of patients who have not had a colorectal cancer screen in the past 12 months? Or have not had a mammogram?

Your program director/residency clinic director should have easy access to all of these above lists; it is one of the few benefits of electronic medical records. If so, all they need to do is print out the lists and divvy them up among residents and medical assistants - then, set aside a half day for a telethon where people just call everyone on the list and tell them to come in for a referral for a mammogram, or a pap, or a diabetes checkup, etc.

Which brings me to another question - if you are barely seeing any patients, what are all the clinic staff doing? Don't you have anyone in the front office or any medical assistants? Are they just sitting around playing games on their phones?

 

[deleted979844]

What's the justification for not counting telehealth encounters? That seems silly.

It's also a disservice to your patients. Patients come to residency clinics because they are one of the few outpatient places that reliably take Medicaid and uninsured patients. By not offering telehealth to patients now, you are either a) depriving them of timely medical care, or b) depriving them of medical care at all.

Does your residency clinic not see OB patients either? They're some of the few patients who absolutely need to be seen on a regular basis, and they cannot always be seen by telehealth.

- I don’t know why telehealth doesn’t count, I had assumed it was a some kind of ACGME rule or something
- we have a large OBGYN clinic in the building that manages all the OB. Residents are heavily involved in it, but again, does not count towards encounters.

If your residency attendings or program directors cannot think of ways to boost clinic numbers, that's a whole other red flag in and of itself, though. There are a ton of ways to "drum up business" and increase volume.

- Do you have a running list of uncontrolled diabetics? How about diabetics who have not had an A1C in 6 months?
- Do you have a list of patients who are delinquent on paps?
- Do you have a list of patients whose last measured blood pressure was over 140/90?
- Do you have a list of patients who have not had a colorectal cancer screen in the past 12 months? Or have not had a mammogram?

Your program director/residency clinic director should have easy access to all of these above lists; it is one of the few benefits of electronic medical records. If so, all they need to do is print out the lists and divvy them up among residents and medical assistants - then, set aside a half day for a telethon where people just call everyone on the list and tell them to come in for a referral for a mammogram, or a pap, or a diabetes checkup, etc.

Which brings me to another question - if you are barely seeing any patients, what are all the clinic staff doing? Don't you have anyone in the front office or any medical assistants? Are they just sitting around playing games on their phones?

- I only wish that our program had been more aggressive about correcting the issue. We huge volumes of patients in auxiliary clinics and put in orders and write notes on them, but they don’t count towards encounters. And it doesn’t seem like any other providers in our area, primary care or otherwise, has a patient shortage anymore. I feel like it’s just our clinic...
-Right now, Whatever volume we have is being diverted to the PGY3 cause they’re so behind. I assume the clinic staff are still plenty busy cause our screening process has become absurdly lengthy.

 

[smq123]

- I don’t know why telehealth doesn’t count, I had assumed it was a some kind of ACGME rule or something
- we have a large OBGYN clinic in the building that manages all the OB. Residents are heavily involved in it, but again, does not count towards encounters.


- I only wish that our program had been more aggressive about correcting the issue. We huge volumes of patients in auxiliary clinics and put in orders and write notes on them, but they don’t count towards encounters. And it doesn’t seem like any other providers in our area, primary care or otherwise, has a patient shortage anymore. I feel like it’s just our clinic...
-Right now, Whatever volume we have is being diverted to the PGY3 cause they’re so behind. I assume the clinic staff are still plenty busy cause our screening process has become absurdly lengthy.

To reassure you, if you're a new PGY-1, I would not worry right now about outpatient clinic volumes. Intern year in FM, in general, tends to be very inpatient heavy, so many FM interns finish their PGY-1 year with pretty low clinic number. That should go up significantly in your PGY-2 year.

What concerns me more, in your case, is that your PD seems either complacent or unable to creatively think up ways to manage the issues that COVID has created. Even as an employed physician, if you're going to survive in outpatient medicine, you have to be able to think outside the box - not just from a business administration viewpoint, but also clinically. So the fact that 7-8 months have gone by and there is still no significant plan on how to adapt the clinic to this is....problematic.

 

[Reboa]

Keep your head down, check the boxes and jump through the hoops they want, contact the office of the omsbudperson at ACGME, they're generally not helpful but it's something that tends to scare them straight or they'll retaliate subtly so don't let anyone know it was you if you do decide to do this.

 

[Bacchus]

Telehealth counts. The ACGME did not say it doesn’t. At the height of the pandemic our residents were doing screening COVID-19 video visits. The ACGME allowed it then so I would double check because our residents still do virtual visits.