Inhouse supervision

[Doctor Bagel]

With the new ACGME rules coming, I was just curious to see how many programs already have inhouse supervision either from attendings or upper level residents. We don't have it here, and it seems to be the biggest potential obstacle for us regarding the new rules.

For those of you who have it, how does it work? Attendings, moonlighters, unlucky seniors?

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[beezley]

Do you mean in house for call? Or for daytime inpatient or daytime outpatient? I am assuming you mean call.

 

[Doctor Bagel]

Do you mean in house for call? Or for daytime inpatient or daytime outpatient? I am assuming you mean call.

I mean for call. I'm guessing all programs would have inhouse supervision during the day.

 

[Doctor Bagel]

OK, so the 3 of you with inhouse supervision on call, who does it?

 

[waldenwoods]

Well, there is always a PGY-2, 3, or 4 resident who is in-house for call. It may not be a system that works universally for all psychiatry programs, but it works well enough where I am, and it just so happens to be in compliance with the requirements for next year.

It sounds like you are concerned about it not being possible in your program. Keep in mind the following language that made it into the new standards (bolding added by me):

In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available. [Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available.]

That part about "with direct supervision available" is defined above that quoted paragraph as off-site supervision. Which is what I'm inferring you do now as a PGY-1--that there is some attending availability overnight, even though the attending is not in-house.

The way I read the above paragraph is that there is wiggle-room to allow PGY-1's to take call without direct supervision immediately available as long as there is some way of measuring that an intern is competent before allowing them to do so. Those competencies haven't yet been published. If you feel it's necessary to the program's viability to require solo PGY-1 coverage in the call schedule, you may want to consider presenting your program's position to the Psychiatry RRC before the specialty-specific requirements are generated. Best of luck.

 

[Rhayven44]

Well, there is always a PGY-2, 3, or 4 resident who is in-house for call. It may not be a system that works universally for all psychiatry programs, but it works well enough where I am, and it just so happens to be in compliance with the requirements for next year.

It sounds like you are concerned about it not being possible in your program. Keep in mind the following language that made it into the new standards (bolding added by me):



That part about "with direct supervision available" is defined above that quoted paragraph as off-site supervision. Which is what I'm inferring you do now as a PGY-1--that there is some attending availability overnight, even though the attending is not in-house.

The way I read the above paragraph is that there is wiggle-room to allow PGY-1's to take call without direct supervision immediately available as long as there is some way of measuring that an intern is competent before allowing them to do so. Those competencies haven't yet been published. If you feel it's necessary to the program's viability to require solo PGY-1 coverage in the call schedule, you may want to consider presenting your program's position to the Psychiatry RRC before the specialty-specific requirements are generated. Best of luck.

Unfortunately, you misquoted there by one word, which makes a huge difference. The requirements states that they can progress to "direct IMMEDIATE supervision." If you notice in the above paragraphs, the ACGME defines a difference between direct supervision and direct immediate supervision; sadly, the latter must stay in house. So any programs without inhouse supervision will change.

 

[waldenwoods]

Unfortunately, you misquoted there by one word, which makes a huge difference. The requirements states that they can progress to "direct IMMEDIATE supervision." If you notice in the above paragraphs, the ACGME defines a difference between direct supervision and direct immediate supervision; sadly, the latter must stay in house. So any programs without inhouse supervision will change.

It is quoted correctly. http://www.acgme.org/acWebsite/home/Common_Program_Requirements_07012011.pdf

 

[Red Beard]

My program has interns without in house supervision after 3 training call shifts. There is going to be a fairly significant restructuring of upper level call (i.e. more call) to meet the probable new guidelines.

Which sucks.

 

[psychattending]

Our program has both PGY1s and PGY2s in house each night; so we will be fine from a direct supervision standpoint as long as the psych RRC does not make the rules any stricter.

 

[DrLanie]

There was some debate amongst residents in my program as to whether PGY-2's qualified as "upper-level" or senior residents, but it sounds as if the general assumption is that PGY-2's do indeed qualify as direct supervisors?

If any case, we always have PGY-2's in-house with the PGY-1's at one site, and PGY-2's and PGY 3's alone at our other sites...so I think we'll be okay as long as this is the correct interpretation. Thoughts?

 

[Rhayven44]

Ah, I see it now. It will be interesting to see how this shakes out for most programs. My personal hope is that 3rd and 4th year residents in programs that have call heavy the first and second years won't get burned by this.

 

[beezley]

I don't know how to quote other posts in my posts, but with regards to hopes that PGY-3 and 4s don't get screwed starting next year
AMEN to that!!

 

[Doctor Bagel]

Ah, I see it now. It will be interesting to see how this shakes out for most programs. My personal hope is that 3rd and 4th year residents in programs that have call heavy the first and second years won't get burned by this.

As a resident at one of those programs, me, too!

 

[Doctor Bagel]

So the bummer here is that it seems like most of the places with inhouse supervision have it done by residents. Now I'm wondering how often the upper level residents are on call to make it work.

 

[hippiedoc13]

We have senior residents (PGY-3 and 4) provide in-house direct supervision of PGY-1s for the first 3 months. After that they are on their own, with a senior resident and an attending both available by phone for supervision.

When I first read the new requirements, I wondered if the phrase "Each Review Committee will describe the achieved competencies under which PGY-1 residents progress to be supervised indirectly, with direct supervision available" MIGHT give us some wiggle room and make a system like ours ok...ie, the PGY-1s do start out with direct supervision, and maybe we could say that by 3 months we expect them to have achieved competencies that allow them to be indirectly supervised. However, in reading the sentences that precede the one quoted, it sounds like the "with direct supervision immediately available" clause would torpedo my hopes. I think the most "senior-friendly" way those rules could possibly be interpreted for a program like mine would be that the senior has to be in-house the whole night, but could be sleeping in the call room and just available if the intern needed him/her. Bummer.

Is this how others are interpreting this as well?

 

[billypilgrim37]

I think reading the clauses like lawyers gets you in trouble, as the spirit of the recommendations (and the ways in which they will be enforced) have been made pretty clear, and most likely there will have to be an attending or an upper level resident (unsure if a pgy2 will count) on the premises. Programs might be trying to interpret this as favorably as possible to avoid having to "do the right thing," but flat out, programs are probably going to have to make significant changes.

Night float and in-house seniors for everyone! Anything less is just going to get your program donkeypunched at some point.

 

[Psychiatrypd]

We are switching things around. We will do primary care the first 6 months, then 12 months of continuous outpatient, then do inpatient after that. Makes better sense anyway. Inpatients are incredibly complex and they only stay 5-7 days

 

[Rhayven44]

I think reading the clauses like lawyers gets you in trouble, as the spirit of the recommendations (and the ways in which they will be enforced) have been made pretty clear, and most likely there will have to be an attending or an upper level resident (unsure if a pgy2 will count) on the premises. Programs might be trying to interpret this as favorably as possible to avoid having to "do the right thing," but flat out, programs are probably going to have to make significant changes.

Night float and in-house seniors for everyone! Anything less is just going to get your program donkeypunched at some point.

PGY-2's count. Its specifically enumerated that anything over a PGY1 is considered a "senior resident."

 

[daru1]

Ah, I see it now. It will be interesting to see how this shakes out for most programs. My personal hope is that 3rd and 4th year residents in programs that have call heavy the first and second years won't get burned by this.

Unfortunately, a lot of them will get burned. Smaller programs more so than larger ones.

As of our meeting Tuesday we are changing our curriculum for 2011. Used to be our 2nd year was some off-site rotations, night float, as well as 3 months of inpatient; our 3rd year was 12 months of outpatient. Next year, they are flipping this, and 2nd year will become 12 months of outpatient, 3rd year will be off-site plus 3 months of being the senior reisdent on an inpatient team.

Basically this means no night float for the next year, and the 2nd AND 3rd class is going to be all outpatient for 12 months. Since they are still holding on to the short call system that the 1st years will cover, someone has to supervise them from 5-9 in house. Here's where our program stepped up for us. They are going to allow the 2s, 3s, and 4s supervise as moonlighting for next year, and the 4th years will do no overnight call.

This might not be too relevant for some programs (since we're doing the cirriculum change), but there's no reason for the night float system to go away. We already have the interns working no overnights, 2nds covering night float; the only change for this year is that 3rd years have to take in-house call on Sundays (small program).

 

[Doctor Bagel]

So it sounds like my program will be getting rid of long call for 1st years because of this supervision issue. I wonder how many other programs will do the same thing. The catch for us is that volume on 2nd year calls is going to double because we're going to cover two hospitals in one night instead of one.

Still curious about how the conversation is going at other programs.

 

[Doctor Bagel]

We are switching things around. We will do primary care the first 6 months, then 12 months of continuous outpatient, then do inpatient after that. Makes better sense anyway. Inpatients are incredibly complex and they only stay 5-7 days

Your post and daru's post are making me wonder if more programs will be moving outpatient experience to first/second year. I know the tradition is definitely to start with inpatient and save outpatient for later in training, but I don't know from an educational perspective why that is. My medical school program had 2nd year as the outpatient year, and that seemed to be really well liked by residents. I've got to admit I would like some more exposure to therapy principles earlier on, and we really don't get that doing inpatient.

 

[WhoisJohnGalt]

So it sounds like my program will be getting rid of long call for 1st years because of this supervision issue. I wonder how many other programs will do the same thing. The catch for us is that volume on 2nd year calls is going to double because we're going to cover two hospitals in one night instead of one.

Still curious about how the conversation is going at other programs.

Our program is really REALLY small (total of 16 residents in years where no one fast-tracks to child), so we're actually considering doing away with overnight call altogether; we just can't find a way to make it work that doesn't involve attendings stepping up to supervise which they're unwilling to do. Now it's just the small matter of convincing the hospital that they can get by without us after 9pm...

 

[Doctor Bagel]

Our program is really REALLY small (total of 16 residents in years where no one fast-tracks to child), so we're actually considering doing away with overnight call altogether; we just can't find a way to make it work that doesn't involve attendings stepping up to supervise which they're unwilling to do. Now it's just the small matter of convincing the hospital that they can get by without us after 9pm...

Wow, that's amazing. And of course they really can get by without you guys being there at night. The ED should technically be competent to decide who to admit and not admit -- that's how it works in EDs without psych residents. And there shouldn't be a need for overnight C/L because honestly hospitalists (and medicine/surgery residents) can handle delirium. You guys could maybe handle admissions on the phone which is how it works just up the turnpike.

 

[gman33]

Our program is really REALLY small (total of 16 residents in years where no one fast-tracks to child), so we're actually considering doing away with overnight call altogether; we just can't find a way to make it work that doesn't involve attendings stepping up to supervise which they're unwilling to do. Now it's just the small matter of convincing the hospital that they can get by without us after 9pm...

No overnight call.

I think I know what program is going to be on the top of my list next year.