New ACGME Accreditation System for Residency - MUST READ!!

[projectlogic]

http://www.ama-assn.org/ama/pub/meded/2012-march/2012-march.shtml

Saw this posted by DrHizzouseMD on reddit.

This struck me to be the MOST relevant thing in the article:

For physicians, one of the attractive features of the milestones concept and the focus on outcomes is the possibility of more flexibility in residency length. If, say, a family medicine resident can meet all the milestones in two years rather than three, there's no reason the doctor could not complete the residency and enter into practice.
Also...

Each of the ACGME's Review Committees in the various specialties, along with specialty medical organizations and specialty boards, are working to design and implement milestones by July 2014. Seven fields—emergency medicine, internal medicine, neurological surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology—will pilot the milestones, with implementation by July 2013.

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[rafman]

Could they be doing this to combat the upcoming GME crunch? If the average post graudate training time decreases, they might be able to have more ppl in their programs.

 

[scotchtapetest]

My question is, then would a resident who doesn't meet the milestones graduate later (e.g. in 4 years instead of 3), because if that's the case then more people will be delayed than other way around, if they truly assess milestones, IMO. Also who is going to determine who has or has not met milestones? Each individual PD? Based on what? Tests/Evals/procedures? That's not fair.... What if the PD is your uncle or hates your guts? Also, what is considered meeting milestones differs at MGH vs. some random community place in the middle of nowhere...

 

[SpecterGT260]

also, there are monetary and funding issues to consider. Might not be huge but many residencies have research years which really only serve to bring grant dollars into a department and put publications out. This could still be a component but I see this getting complicated if we go by competencies instead of time.

in addition, there is a significant argument that competency cannot always be directly assessed via testing and that time is the only true measure. I could cram for step 3 and pass, but without the required years under my belt the retention will probably suffer

 

[BigPizza]

Sorry to be off-topic, but they didn't mention anything about increasing residency spots

Anyone knows what's going on with increasing residency spots?

 

[Raryn]

Sorry to be off-topic, but they didn't mention anything about increasing residency spots

Anyone knows what's going on with increasing residency spots?

CMS recently redistributed 600-700 spots that were previously assigned to programs that had gone defunct or were otherwise not being used, so the number of available spots should go up by ~200/year or so during the next few years.

Otherwise, the cap from 1997 still applies. There's a bill in the senate to increase the number of spots by 15%, but it doesn't really have a hope of passing.

In other news: President Obama's proposed budget cuts total residency funding by 10% for the next 10 years while nominally leaving the number of spots the same, using the reasoning that CMS is giving programs too much money/resident and they will be fine with less. Also, it cut peds residency funding by 67%, using the same reasoning. (Peds residency spots have their own funding supply through Childrens Hospital grants)

 

[dd128]

Sorry to be off-topic, but they didn't mention anything about increasing residency spots

Anyone knows what's going on with increasing residency spots?

I was somewhat curious about this myself and haven't seen much info anywhere about when they'll be increasing the number of spots, as it's only logical right? I brought this up when I was chit chatting with a PD a month or so ago, and the general consensus is that they won't be increasing spots any time soon. He assumed that at some point when it's clearly evident there is a vast physician shortage they may start increasing spots again. Who knows when that will be...

 

[Raryn]

I was somewhat curious about this myself and haven't seen much info anywhere about when they'll be increasing the number of spots, as it's only logical right? I brought this up when I was chit chatting with a PD a month or so ago, and the general consensus is that they won't be increasing spots any time soon. He assumed that at some point when it's clearly evident there is a vast physician shortage they may start increasing spots again. Who knows when that will be...

The money just isn't there unfortunately. They are already well aware of the need to increase spots, but they're also debating how much to cut GME funding, not about the need to increase it. (See above regarding the administrations current proposed cuts to residency funding. It's better than the 60% funding cut being debated last year, but still)

 

[SteinUmStein]

The money just isn't there unfortunately. They are already well aware of the need to increase spots, but they're also debating how much to cut GME funding, not about the need to increase it. (See above regarding the administrations current proposed cuts to residency funding. It's better than the 60% funding cut being debated last year, but still)

In all seriousness, who is going to treat all the baby boomers? There aren't nearly enough of us to do it, not even close. 😕

 

[Sephiroth]

In all seriousness, who is going to treat all the baby boomers? There aren't nearly enough of us to do it, not even close. 😕

Sounds like a self-solving problem then.



But in all seriousness, the AARP is the largest/most powerful advocacy/lobbying group in the country. Once there is a clear issue, they will start doing something to make sure they don't get f'ed. The real question though is how far in advance and how quickly they will act.

 

[SteinUmStein]

Sounds like a self-solving problem then.



But in all seriousness, the AARP is the largest/most powerful advocacy/lobbying group in the country. Once there is a clear issue, they will start doing something to make sure they don't get f'ed. The real question though is how far in advance and how quickly they will act.

It seems like the political foresight in our system is limited to around 6 months to one year into the future, which isn't fast enough to react to this scale of changing demographic. I hope the AARP realizes how much lag time there is on things like establishing new medical schools and opening new residency spots.

 

[scotchtapetest]

The milestones concept looks promising if one could theoretically finish residency sooner. I could see this as a tremendous plus for family medicine residents.

and a tremendous minus for their patients....

 

[SpecterGT260]

I really wouldnt trust this system.... many docs ive talked to (including a currently practicing neurosurgeon) said that they really didn't get all of the kinks ironed out until well after getting board certified. sure... you know the drill and the routine, but in many cases there will be aspects of your practice that you dont REALLY understand until its been done for awhile. the ability to re-create doesn't denote mastery, but re-creation can be done with a very high degree of accuracy in very little time. IMO time is a necessity regardless of how talented a resident seems.

 

[neusu]

many docs ive talked to (including a currently practicing neurosurgeon) said that they really didn't get all of the kinks ironed out until well after getting board certified. sure... you know the drill and the routine, but in many cases there will be aspects of your practice that you dont REALLY understand until its been done for awhile.

In the name of patient safety the whole training paradigm has changed from being a resident run hierarchical training program to an attending run forced labor program. For what its worth, I sometimes wonder at, at some programs, if the program purposefully under-trains the residents to force the need for fellowship training and inhibit competition in the local vicinity.

Take your average neurosurgery program. First year is technically "owned" by neurosurgery, but it's still a general surgery internship just like orthopedics. Second year is floor/ICU scut year. Third/Fourth/Fifth/Sixth year is a combination of additional scut/junior operative/electives/research. Seventh year, finally, you're a chief. But you're hand held the entire time. It's great to have a safety net, but you'll never learn to fly when someone is holding you up.

 

[SpecterGT260]

When every surgery carries with it a substantial lawsuit risk I'd hold the resident's hand too.....


this is me agreeing with you lol

 

[SpecterGT260]

Explain. How could finishing up 6 months to 12 months early be a minus for patients if the individual Family Medicine resident has shown competence as outlined in this proposal?

he is saying the proposed measures of competence are insufficient to really assess the ability of a resident to practice solo and therefore the system will actually turn loose less than competent doctors

 

[SpecterGT260]

of all of the proposed benefits, patient outcomes is not listed..... nor should it be because this is a framework for a system intended to be tracked to assess impact on patient outcomes later.

 

[SpecterGT260]

Could you explain how the current system is any different now?

The current system assumes that time is sufficient to ensure when a resident is "done".... similar to cooking a souffle.... you don't want to take that sumbitch out too early or it will crash on you.

Nobody is saying this is perfect. And also, nobody is saying that a quantitative system to assess performance is a bad thing or is not needed.

what IS being said is that this proposed system may
1. inadequately predict readiness to practice solo.
2. promote situations of pre-mature graduation and certification from the program

Maybe the system CAN predict readiness.... but even so, without a minimum time requirement there is always potential for programs to graduate residents early for whatever reasons - graduate your chiefs in favor of paying an interns salary instead maybe? dunno how realistic that is but it is on the table

 

[scotchtapetest]

Explain. How could finishing up 6 months to 12 months early be a minus for patients if the individual Family Medicine resident has shown competence as outlined in this proposal?

First of all, how competence is measured/evaluated requires another discussion thread which is my biggest problem with this proposal.... What objective criteria will be used? Who can kiss ass or suck up to the attending/PD better?

Also, This is not about any specific residency program.... There is some value to supervised time, experience and exposure that no measuring tool/criteria can replace. If FM residency can be shortened by 12 months (i.e. 33%) then theoretically IM/surgery/any other residency could also be shortened by 33%... Could you imagine an Internist graduating as PGY2? (btw, they provide the same care that FM physicians provide or at least that's what FM physicians claim).... Or surgery resident graduating as PGY 3.5? This is all considering that first half of intern year is wasted on remembering the crap you forgot during 4th year and finding where the bathrooms are, while the second half is spent doing scutwork... So by the end of PGY2, one has only really "practiced" 1 year of legit medicine.... I don't care how smart you are, or how many competency measures someone said you have demonstrated/mastered, I don't want you anywhere near my family (without direct supervision) as a PGY2....

 

[IlDestriero]

he is saying the proposed measures of competence are insufficient to really assess the ability of a resident to practice solo and therefore the system will actually turn loose less than competent doctors

Absolutely. This is a horrible idea. Anesthesia has minimum case numbers required for graduation. However, most good programs greatly exceed these numbers. You learn the most by routinely doing very complex cases. It's the big advantage of the powerhouse specialty programs over run of the mill community programs. You don't need to do hundreds of bread and butter cases to be competent, but if you can make the sick as stool train wreck patients look easy, you know you're a superstar. That's where you learn how to deal with complications, etc.
Graduating early because you meet the minimum standard lowers the bar, nobody should aspire to meet the minimum requirements for anything.👎