Logging Procedures

[Llenroc]

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As usual, you're always doing stuff in life without really understanding what the end result is, or how important whatever thing is.

Now that I'm in the procedural stage of my residency, what exactly do I need to be concerned about? Of course, I log everything. I even log non-procedural encounters. But at the same time I still need a sense of "what do I need to pursue" so I can figure out my electives correctly, and even figure out which attending I need to go with on a particular day, or even - minute to minute - figure out which patients I need to see on a given list.

I know we need 200 EMG's, which I think I'll probably get. But who actually checks and "accredits" these things. Is someone going to stop you from doing EMG's if you don't have 200 of them?

And what about *everything else*? How many botox injections do I need to as a resident to be able to do them legally and get paid for them as an attending? What about trigger point injections? What about knee injections? And are Synvisc shots a different category entirely? What about flouroscopic procedures?

Finally, what's the deal with procedures that you've only *observed*. Does that even count for anything? Of course, I still log them. But is that doing me any benefit that I observed them, rather than performed them? "Assisted" does not seem to be an option on my logging system. They're all either "performed" or "observed".

 

[Ludicolo]

I’m going to summarize the ACGME party line here.

The case/procedure logs serve threefold. 1) Lets the PD review your experiences so he/she can get a sense of what procedures and patients you still need exposure to. The PD can use your case log to “certify” that you have adequate hands on experience with EMGs, injections, etc.; SCI, amputee, peds, etc. That “certification” permits you to sit for the PM&R written boards. PDs can also include this info in LORs to future fellowship directors or employers. 2) Lets the RRC review all of the residents’ experiences so they can assess whether or not a program is providing adequate educational and clinical exposure, which factors into a program’s accreditation status. 3) Lets you personally review your experiences, so you can get an idea of what you need to work on.

When it comes to physiatric procedures, only EMGs have a quota you need to attain to allow you to sit for the PM&R boards (as an aside, you’ll need an additional 200 out of residency in order to sit for the EMG boards). Technically speaking, no one can stop you from performing EMGs, Botox, fluoro, or even cosmetic surgery on your own as long as you have a medical license. But individual institutions and malpractice lawyers have their own credentialing standards.

In the eyes of the ACGME, “observed” counts toward the 200 EMGs as much as “performed”. Every new procedure you learn you have to observe at first. But by the end of residency, for your personal benefit, you should be performing much more than observing. See one, do one, teach one. And I would hope that the RRC looks more favorably on programs that let residents perform rather than observe.

 

[PMR 4 MSK]

When I joined my current practice 5 years out from residency, one of the hospitals gave me grief trying to get credentialed to do pain management procedures. I was the first Physiatrist to apply for them. My PD from residency retired the year I graduated, and her office in the "old" building closed. My logs were lost. I did not keep them after residency as I did not think I would need them. They ended up asking me to supply them with a copy of every procedure report I had done over the intervening 5 years. It took 2 days and 4 people with me to get these reports. They grudgingly gave me pain management procedure privileges.

It's unlikely you'll need a log of EMGs, usually your PD will couch for you that everyone in your program has 200+.

For every other procedure you do, log them. Have the supervising attending sign off at the time on your log.

 

[VApmrdoc]

For credentialing I had to fill out a form which had various procedures I was asking to be eligible for within our field: a certain number they required and a certain number you could enter you had done. Now I don't know if they confirmed these numbers but no one asked me for a copy of my procedure logs. I'm in a relatively simple situation though, so I would think that if you have any thoughts of doing more interventional procedures or EMG/NCS, it isn't going to hurt to keep it logged.

When you've done your 50th knee or shoulder injection, I really don't think people care anymore - unless its US guided which may prove to be useful in the future.

Maybe an interventionist can comment on the fluoro aspect as I am sure there is additional training you need to be certified for in terms of operating the machine (which I think is actually reimbursed better than the injection itself???).

 

[RUOkie]

When I joined my current practice 5 years out from residency, one of the hospitals gave me grief trying to get credentialed to do pain management procedures. I was the first Physiatrist to apply for them. My PD from residency retired the year I graduated, and her office in the "old" building closed. My logs were lost. I did not keep them after residency as I did not think I would need them. They ended up asking me to supply them with a copy of every procedure report I had done over the intervening 5 years. It took 2 days and 4 people with me to get these reports. They grudgingly gave me pain management procedure privileges.

It's unlikely you'll need a log of EMGs, usually your PD will couch for you that everyone in your program has 200+.

For every other procedure you do, log them. Have the supervising attending sign off at the time on your log.

If there is a chance that you will be practicing in a rural community, I highly recommend logging your EMG's. We (a neurologist and I) are the credentialling committee for EMG at our hospital. In the past 7 years we have had to take away or deny EMG privileges to 3 physicians because of lack of training. Many PD's do not take the time to fill out the hospital credentialling packets fully, or they just check the box that says "they did their training here" and write a note that they ASSUME that 200 were done. That is not acceptable, and then the trouble starts.

 

[RUOkie]

OP: in short, I would track everything. I didn't do it, but would now.

 

[DOctorJay]

I am diligently tracking my procedures but find it ridiculous in this climate where we are allowing nurses to do just about whatever they want while making it harder for doctors to do what we are trained to do.

 

[PMR 4 MSK]

I am diligently tracking my procedures but find it ridiculous in this climate where we are allowing nurses to do just about whatever they want while making it harder for doctors to do what we are trained to do.

Welcome to the future of medicine!

I don't know why anyone in college right now is seriously thinking about medical school. You can go to nursing school followed by an advanced RN degree and do less school, do less work, work better hours, and get paid more than many doctors. Plus all your patients will think you are a doctor and like you better.

 

[surftheiop]

Welcome to the future of medicine!

I don't know why anyone in college right now is seriously thinking about medical school. You can go to nursing school followed by an advanced RN degree and do less school, do less work, work better hours, and get paid more than many doctors. Plus all your patients will think you are a doctor and like you better.

They said the same thing about dot.com's and real estate, I'm waiting for the "nursing bubble".

When its bursts, remember you read it here first 😉

(Or maybe I'm just trying to justify starting med school next fall 😱 )