Graduated Responsibility

[zao275]

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Everyone talks about this and it seems like most people don't really know what it means or how to incorporate it into their training programs. We discussed this in the CAP Residents Forum quite a bit and one idea we had was to collect stories/ideas/concrete examples from other residents and fellows in regards to how they are experiencing graduated responsibility in their residency programs. I created a new page on the wiki to keep track of all of these suggestions. If any of you have anything to add to it, I would be greatly appreciative!

Thanks!

http://pathinfo.wikia.com/wiki/Graduated_Responsibility_During_Pathology_Residency_Training

 

[zao275]

Seriously? In this entire (very opinionated) forum there is NO ONE who has a comment to make about Graduated Responsibility? Not even PathStudent? ;-) If you guys want to just add your comments to this thread (rather than to the wiki), I would be happy to cut and past them to the wiki (either anonymously or with credit to your userID, whichever you prefer...if you want it to be anonymous just mention that in your post please). I would really love to hear what all of you have to say about what graduated responsibility really means and how in the world it is practically applied in your training program. Your comments could potentially help a lot of people (or that is what we hope for at least).

 

[Gene_]

Okay, I'll bite.

What is it? Asking residents to assume more responsibility as their pathology skills improve.

Examples from my training: teaching first year residents, calling frozens on my own, autonomy in ordering specials/recuts, calling consulting pathologists to discuss cases sent to my insititution, and participating in CAP inspections. These are all things I didn't do as a first year, but was slowly given these responsibilities as my abilities/experience increased through residency.

 

[KCShaw]

I'm more of a mind that it -should- mean -demanding- residents/fellows assume more responsibility as their program director feels they become more qualified to do so. If you're willing to send a resident/fellow off to be an attending, you should be willing to let them sign out essentially independently by the time they complete the program.

Unfortunately, billing &/or insurance seems to pretty much prevent even senior residents from becoming "autonomous," except in limited circumstances -- some programs allow senior residents to independently handle certain frozens/overnight transplant biopsies/autopsies/common not-usually-tumor specimens such as gallbladder or appendix. However, IMO, the expectation should be that by (if not before) a resident completes the program their attendings should be quickly reviewing & co-signing rather than sitting down for a joint sign-out, except occasional cases the resident flags (i.e., knowing their own limitations). If the program attendings aren't confident in this, then they probably shouldn't be confident graduating that resident to go work somewhere. But my impression is that a lot of programs only pay lip service to the concept of graduated responsibility and leave it at teaching junior residents and handling tumor boards basically on their own (work most attendings consider "busy work"). Or they only progress to this level with rare "special" residents, instead of truly expecting it from everyone.

So while I agree that Gene_'s examples describe graduated responsibilities, personally I think the end point should be an expected/demanded one functionally equivalent with that of so-called junior faculty. But for the most part I'm not sure I see that happening with regularity outside of the fellowship setting.

 

[pathstudent]

It is tough for pathology. Jr path residents don't like signing cases out to senior residents. Cms rules don't allow depts to bill for work done by residents. So residents can read frozens on their own or do fnas or do adequacies or bone marrow biopsies but if the act is not observed directly by a licensed physician the program cannot bill for it.

 

[Napoleon1801]

Calling adequacy on biopsy specimens would probably be a good addition.

Anyone know how the radiologists get graduated responsibility? It seems like a similar type of training....

 

[pathstudent]

Calling adequacy on biopsy specimens would probably be a good addition.

Anyone know how the radiologists get graduated responsibility? It seems like a similar type of training....

Calling adequacy is great but if an attending doesn't review it at the time, then you can't bill for it. Trust me I am all for resident indepedence but even at top tier programs which I prefer and work at, we are run like businesses who are always trying to maximize profit.

The days are done when academics can sit in their ivory towers and write papers.

 

[lipomas]

The problem for unmotivated residents, and there are a lot of residents who cannot motivate themselves, is that becoming good at pathology requires you to take a lot of initiative yourself. Graduated responsibility is all well and good but you can do other things. There are limits, as others said, to what is allowed. If you treat preview time seriously and not just glance at cases and come up with a differential so you can get home to play WoW you will be better off. After my first two years I started doing that with preview time, and formulating reports to some extent during preview time. My skills improved exponentially along with confidence. Same with frozens - if programs don't allow you to sign them out on your own then pretend you have to - don't show it to the attending until you know what you would say.

 

[2121115]

Does true graduated responsibility even exist in pathology training? I don't think so.

 

[Unty]

Pathology requires A LOT OF PRACTICE. I don't believe previewing your own cases on a rotation is enough. You really need to look at many old cases...as much as you can and try to come up with your own diagnosis without looking at how the case was signed out. Also, understand why certains stains were ordered. If you have any questions, take it to a senior or attending.

Nothing really prepares you for clicking that "signout" button with your name on the case!

 

[Napoleon1801]

Calling adequacy is great but if an attending doesn't review it at the time, then you can't bill for it. Trust me I am all for resident indepedence but even at top tier programs which I prefer and work at, we are run like businesses who are always trying to maximize profit.

The days are done when academics can sit in their ivory towers and write papers.

Cytotechs do this all the time without an attending though...?

 

[pathstudent]

They are not trainees and the pathologist cannot bill for their work either. The CPT code for a touch prep is an 88333 and for a fna adequacy it is an 88372 or 88373 (the other is for FNA interpretation). Only pathologists can bill those codes. I think there is a code for cytotechs but it pays far less.

These laws came about because the CMS (or whatever it was called at the time) wanted to make sure that the government wasn't paying out money to doctors for work done by trainees. You can see how on in a busy ER or busy medicine service how that could end up happening.

In fact it happened to me. I went to a city hospital with a e.med residency program with something that ended up being nothing. I was seen by a resident who examined and had me get an x-ray which she read herself. She was going to get her attending to see me. She couldn't find her attending and said "why don't you just take off". I said OK but ended up getting a bill for 400 for the emergency attending as I was uninsured. I didn't pay it because he never saw me. I called his department and the billing office for the hospital and protested it and said that he never once laid eyes on me.

The CMS probably does end up paying doctors for work they never did all the time, small things like CT adequacies or frozen sections or 88300s and god knows what else. But you would be at risk for medicare fraud.

 

[zao275]

Wow. Thanks for all the responses. I have been too busy to check the forum the last few weeks, between board exam, moving to another state, and starting fellowship. Do any of you object to me posting your comments (in quotes and citing this thread) on the Wiki? If you would like me to cite your individual username, please just let me know. I want to populate that part of the wiki with data in order to encourage others to add to it (including people who may not necessarily post on SDN). Your comments will be posted here:

http://pathinfo.wikia.com/wiki/Graduated_Responsibility_During_Pathology_Residency_Training