Bad Teaching Attending to be Next APD?

[twinklecake426]

Hi everyone, longtime lurker since the pre-med days. Been wondering about the best way to deal with a residency issue recently. In short, I’m at a community program in an area with other academic centers and community programs. One of the program graduates took on an attending job at the hospital and has been aggressively rising up the power chain, currently 2 years out in practice. He’s now been selected as our APD, which I would be much less concerned about if he were interested in teaching and provided valuable experiences.

He has been pushing for more notes and coding phrases in order to bill for them to the extent that sometimes we are redoing notes 3+ times in order to get all of his billing codes. He has managed to get to a point where he is attending on the majority of every team's patients, so he essentially gets all of his patient billing strictly through us. Our work with him primarily consists of calling the floor to inform nurses of his updates, or we will have to contact consultants to confirm what they wrote in their notes. Many other examples as well. I know some of it is just part of training, taking things you don’t like and dealing with people you’d rather avoid.

At this point however, it’s starting to impact my education more than I’m ok with but don’t know if there’s much I can do about it. Any feedback on this? Thank you so much!

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[rokshana]

Hi everyone, longtime lurker since the pre-med days. Been wondering about the best way to deal with a residency issue recently. In short, I’m at a community program in an area with other academic centers and community programs. One of the program graduates took on an attending job at the hospital and has been aggressively rising up the power chain, currently 2 years out in practice. He’s now been selected as our APD, which I would be much less concerned about if he were interested in teaching and provided valuable experiences.

He has been pushing for more notes and coding phrases in order to bill for them to the extent that sometimes we are redoing notes 3+ times in order to get all of his billing codes. He has managed to get to a point where he is attending on the majority of every team's patients, so he essentially gets all of his patient billing strictly through us. Our work with him primarily consists of calling the floor to inform nurses of his updates, or we will have to contact consultants to confirm what they wrote in their notes. Many other examples as well. I know some of it is just part of training, taking things you don’t like and dealing with people you’d rather avoid.

At this point however, it’s starting to impact my education more than I’m ok with but don’t know if there’s much I can do about it. Any feedback on this? Thank you so much!

Have you talked to your chief about this? Not that necessarily s/he can do anything about it , but they maybe able to discuss with your PD and the. They on turn can speak to this APD about it.

 

[twinklecake426]

Have you talked to your chief about this? Not that necessarily s/he can do anything about it , but they maybe able to discuss with your PD and the. They on turn can speak to this APD about it.

Thanks so much for your reply! Have discussed with our current and future chiefs numerous times already- has been ongoing for several months at this point. Unfortunately, in particular our future chief has not shown a strong interest in bringing up and addressing these concerns despite numerous complaints.

 

[deleted480308]

So he’s particular about billing notes? That’s annoying but is just something you deal with

What’s the thing that is actually the problem?

 

[twinklecake426]

So he’s particular about billing notes? That’s annoying but is just something you deal with

What’s the thing that is actually the problem?

I would say its that he's restricting our exposure and variety of training, as most of the residents have admitted only with him for months. Personally I have had minimal interaction with any other attending except him for my past 4 months on wards. Regardless of his skills, I don't think its appropriate to learn all of our medicine from a single attending. For context, we have 30+ hospitalists on staff that have all at some point admitted with us. I suppose the billing issue is just all the more frustrating when its added on top. I know from my previous institution its not uncommon to work with someone for an entire month, but generally after that you will work with someone different in the future months.

Unfortunately, I don't think there is much teaching even when working with him- he generally has a plan in mind already that he tells us to complete, and then the rest of the day is spent scheduling appointments and tests, collecting outside records, calling nurses and CNLs to "update" them. Throughout this he will repeatedly contact you to ask if things are done. Of course I 100% understand these are still essential to completing patient care and part of moving along the patient's treatment plan and getting them ready for d/c in a timely fashion, and I have no problem doing these tasks; its when it becomes our sole purpose is completing these without having any chance to take part in the medical management.

As a side note as well- when we admit patients that are not with him on our call days, he will look through these charts and contact us to critique our management.

 

[Crayola227]

Complaining was a bold move. Seems like it's not likely to do any good to continue, and it could have significant harms, especially if he's an aPD.

Seems like it's time to ask, "How high?" and "How wide?"

 

[twinklecake426]

Complaining was a bold move. Seems like it's not likely to do any good to continue, and it could have significant harms, especially if he's an aPD.

Seems like it's time to ask, "How high?" and "How wide?"

Thanks so much for your reply- would just like to clarify this has been a group effort of our entire intern class (100% of us have been in agreement). Most of the complaints have not been personally made by me, but doesn't necessarily change your point. Appreciate your response.

 

[Gastrapathy]

Do the other attendings want to admit to the teaching service?

 

[MSTP18]

Just want to throw it out there that I can easily envision a scenario where someone is incredibly skilled at managing a residency program without being the best bedside teacher themselves. That may or may not be the case here but I don’t automatically assume bad teacher on rounds = bad program director.

 

[Dr.LeoSpaceman]

As a side note as well- when we admit patients that are not with him on our call days, he will look through these charts and contact us to critique our management.

In other words, he'll teach?

I think it's appropriate in certain situations for trainees to raise concerns about faculty. But when doing so, you need concrete information and examples. The way you are describing it here seems a bit nebulous, which isn't going to help your case. I agree with you that being exposed to a variety of faculty is advantageous, but recognize that other faculty probably like the fact that he's willing to do more than his share and as such may not be sympathetic to that argument.

The issue of him offering little autonomy to the residents is perhaps your better angle. But even that may not get a lot of traction if he is otherwise productive. Some attendings are more "hands-on, and I suspect that's the view you'll hear from the department.

I also agree with others that the qualities you're mentioning are likely the reason he's being tapped to be an APD, so I suspect you aren't going to get far with your issues. A better way to approach this (instead of trying to ice out one attending), is to go to the PD and express your interest in continuing to work with a diverse group of attendings. Make it less about him, and more about what you feel is important to your development.

EDIT: To add to this post, I'd say in my mind there are 3 general reasons I'd consider "reporting" an attending:

1) Fraud
2) Negligence
3) Abusive/discriminatory behavior to staff or trainees

Short of that, I'd be hard pressed to believe there would be any type of change considered. Like any profession, everyone is different and some people are harder to work for/with. You will have your chance to review him in evaluations, and you should certainly take that opportunity. But escalating above that is a bold move that can backfire even when there are appropriate grounds for doing so.

I'd also suggest you consider that while the note writing issue (which I get is just an example) is teaching you something: How to document appropriately so that it can be coded appropriately. This is cumbersome and annoying now, but will be something important to know when you are an attending. It's like I used to get annoyed about attendings who wanted things prepped/draped a certain way, or lights/bed positioned in a particular manner. At the time it was annoying to be beat on for what I considered minutiae. Now that I'm starting to be responsible for actually doing the case, I recognize why these details are important.

 

[rokshana]

In other words, he'll teach?

Though is that not the job of the attending of those pts? As an attending, I would be a little annoyed if another attending decided to weigh in on my pt and how I was teaching the residents on that pt.

I agree, that the residents are getting benefit from learning how to write a note that get the best billing...it’s funny how as residents get so little in learning to bill, but come July 1st,as an attending, one is expected to be an expert!

To the OP, you said he was a recent graduate and this may be part of his learning curve...new attendongs can have some difficulty with delegating and letting go of micromanaging...when the safety net of having an attending goes away it can be a bit scary! Once he gets a little more comfortable in his skin, he may ease up.

 

[evilbooyaa]

New attendings are routinely micromanaging if they do not have confidence in you (which as an intern, will be always). This is true across most specialties.

I'm assuming your not peds, where attending hand-holding is routine and resident independence is essentially unheard of.

Is the attending teaching you medicine? You pre-round in the morning on the patients before discussing with the attending right? Do you know what you want to do with each patient before he tells you the plan? If so, then mention anything you think of that he hasn't mentioned when he 'tells you' what to do on each patient. If not, why not? Avoid complacency - you are training to be an independent attending. Try to have a plan of your own at all times.

 

[IMreshopeful]

Yeah, idk, it’s hard to judge this in balance without actually seeing what’s going on. I had a variety of teaching attendings at my upper mid tier academic residency. A few ways they were different:

- one attending was a hospital admin and would basically run the list, do grand scheme planning (leaving most of the medicine minutiae to the senior), and her teaching was mostly geared around discussing CMS regulations and what kinds of things are appropriate and not to treat in the hospital. It was helpful but not real “medicine” education I guess
- couple of meh attendings who would come, round, dictate plans, complain about things, and then were nowhere to be found later. Good independence, zero teaching. One of these was an APD
- a GIM attending who was very traditional in teaching style - would round with team, see patients with team, do bedside teaching and then afternoon didactics
- etc etc

The subspecialty teams (MICU, onc, cards) would have their own style which was unique to their patients and were much more involved.

I guess my point here is that there are a variety of styles of teaching. Your attending is personally calling and critiquing your plans and teaching you appropriate billing - that’s pretty good for someone a few years out of residency. This stuff matters. Tbh I found that most stuff in IM can be learned by reading up on your patients particular pathology and seeing what gets done... mostly, and most importantly, it’s important to remember that medicine is an art as much as a science and as such you may develop your own way of doing things which doesn’t necessarily reflect exactly how you were taught

 

[IMreshopeful]

New attendings are routinely micromanaging if they do not have confidence in you (which as an intern, will be always). This is true across most specialties.

I'm assuming your not peds, where attending hand-holding is routine and resident independence is essentially unheard of.

Is the attending teaching you medicine? You pre-round in the morning on the patients before discussing with the attending right? Do you know what you want to do with each patient before he tells you the plan? If so, then mention anything you think of that he hasn't mentioned when he 'tells you' what to do on each patient. If not, why not? Avoid complacency - you are training to be an independent attending. Try to have a plan of your own at all times.

I agree with this. It’s important to have plan already in place even if you’re wrong. I hate it when my residents and interns would present an H&P or a daily note or whatever and then be like “so what do we do?” Youre a doctor, tell me what you want, I’m not here to spoonfeed you

I also learned this about peds when I rotated on the peds cardiology unit as an adult fellow... the attendings dictated pretty much everything up to exact medication dosage and when to order things like Tylenol (which the attendings in IM could care less about micromanaging)

 

[Crayola227]

Thanks so much for your reply- would just like to clarify this has been a group effort of our entire intern class (100% of us have been in agreement). Most of the complaints have not been personally made by me, but doesn't necessarily change your point. Appreciate your response.

I appreciate that it wasn't just you bringing issue, my comment was meant to be pretty broad. Complaining in residency, is a bold move, period. It can always backfire no matter what PGY you are, your specialty, or who you are complaining about.

Lastly, it never inspires confidence when it's interns saying a damn thing. People have to basically be dying in a lot of cases, before your complaints are viewed to have merit. No, really. That was my experience.

It looks to me like a lot of people here, already, are sort of wondering if the interns know enough to actually determine how bad a teacher he is, and if he is even so bad as to warrant any sort of action.

Just food for thought.

Partly because I think a lot of people have some perspective on things we thought/felt as med students/interns, and how we later reflected on it as we learned more. Sometimes you were spot on something was terrible, and other times you were way wrong. I'm not sure your class will really know until you have more experience, and in any case, even if you're right, it won't really matter, because a lot of the people above you understand all of what I just said and are likely applying it in protection of this attending who clearly has some support for whatever reasons, that have brought him to where he is today.

 

[NotAProgDirector]

As a PD, if you think there is a problem with any of my faculty, esp my APD's, then I would want to know about it. But all we have is your word that this person is a problem. If it truly is "the whole class", then you can bring it up. Also, most programs do an anonymous annual review this time of year, could put it on there.

 

[mvenus929]

I agree with this. It’s important to have plan already in place even if you’re wrong. I hate it when my residents and interns would present an H&P or a daily note or whatever and then be like “so what do we do?” Youre a doctor, tell me what you want, I’m not here to spoonfeed you

I also learned this about peds when I rotated on the peds cardiology unit as an adult fellow... the attendings dictated pretty much everything up to exact medication dosage and when to order things like Tylenol (which the attendings in IM could care less about micromanaging)

I realize my Peds program was awesome in this respect, but my gen Peds attendings let me run the service as a senior with some supervision, but with definite autonomy. The Peds cards patients are a special population compared to the rest of Peds, because they are seen as more fragile and vulnerable. Heme-Onc was similar. My residency PICU service was similar, but that’s cause we had less than great attendings... I had pretty good ownership of my patients as a med student in the PICU at a different institution.

 

[IMreshopeful]

I realize my Peds program was awesome in this respect, but my gen Peds attendings let me run the service as a senior with some supervision, but with definite autonomy. The Peds cards patients are a special population compared to the rest of Peds, because they are seen as more fragile and vulnerable. Heme-Onc was similar. My residency PICU service was similar, but that’s cause we had less than great attendings... I had pretty good ownership of my patients as a med student in the PICU at a different institution.

Yeah, no doubt they are incredibly complex patients. I guess in IM the residents at least at my institution after a few months are given essentially full reign to do whatever so it’s just interesting to see seniors basically having to addend every H&P of their interns (which in turn is addended by the fellow and attending)... the idea was just so foreign to me lol