NEW ACGME regulations

[amygdala_path]

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Hi guys,
New ACGME requirements are that PGY1 residents are under direct supervision of an attending. What are the changes being made in your program in this regard?
I heard that some programs are considering not having PGY1s gross any large specimens in the first year. Do you think this is acceptable? Please share your thoughts......

 

[2121115]

Hi guys,
New ACGME requirements are that PGY1 residents are under direct supervision of an attending. What are the changes being made in your program in this regard?
I heard that some programs are considering not having PGY1s gross any large specimens in the first year. Do you think this is acceptable? Please share your thoughts......

Hahahahahahahah!


LOLOLOLOLOLOLOLOLOLOLOLOL!!!!!!!!!!!!!!!!!!!

 

[TMZ2007]

Define "large" specimens. Like biopsies only?

 

[TMZ2007]

Furthermore, it would seem that a phone call along the lines of "Hey boss, come show me how you want this lung/larynx/whipple cut in" would satisfy this requirement well enough.

 

[2121115]

I'm sure there is some qualifier that allows for PA's as "physician extenders" to supervise residents in the gross room. Also, I'm sure that "direct" supervision will be interpreted pretty broadly. The idea of a pathology intern not grossing larges without an attending standing beside them is just preposterous, which is what a rule like this would require if interpreted strictly.

Just no way it will happen. If it did, there would be no reason to have interns.

 

[pathstudent]

I'm sure there is some qualifier that allows for PA's as "physician extenders" to supervise residents in the gross room. Also, I'm sure that "direct" supervision will be interpreted pretty broadly. The idea of a pathology intern not grossing larges without an attending standing beside them is just preposterous, which is what a rule like this would require if interpreted strictly.

Just no way it will happen. If it did, there would be no reason to have interns.

I don't know. I have seen a few specimens ruined by first-years that didn't ask for help.

Isn't there going to be a 68 hour rule now for interns? i have heard rumors

 

[2121115]

I don't know. I have seen a few specimens ruined by first-years that didn't ask for help.

Isn't there going to be a 68 hour rule now for interns? i have heard rumors

So have I.

 

[icpshootyz]

Granted, we have 1st years screwing things up all the time because they don't ask for help on specimens they're unfamiliar with. But there's no way to mandate that an attending stands over their shoulder 24/7, either. I assume this just means what another poster said, that somehow the 1st year must document that they at least discussed the specimen with their attending (or a fellow, or PA, or whatever).

 

[KCShaw]

I've searched briefly through this, which, according to it, goes into effect July 2011:

http://www.acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf

...and I saw nothing alarming. It does, however, indicate the individual review committees are responsible for determining at what levels direct vs indirect supervision are required. According to the ACGME website, the Pathology RC meets April 8-9. Seeing as how the Path RC still appears to have a say, I can't imagine a true blanket "every PGY1 must be under direct faculty supervision while grossing, all year" or similar.

Edited to add: I also didn't see anything about changing the basic 80 hr work week. If they changed some of the details of time off between shifts, etc. etc., I don't know. It does say PGY1's can't be scheduled to stay in-house >16hrs at a time, but PGY2+'s can be scheduled for up to 24hrs in-house at a stretch...sorta, with the exception that they could stay four more hours to hand off (I don't think that's new), or if they CHOOSE to they can stay to provide care for 1 patient. I did see that "strategic napping...is strongly suggested" while working, which is quite nice of them to include -- never saw that before. Most of this still doesn't generally apply to pathology in any practical way, except that your friends in other residencies are probably still in programs which struggle with the concept of a dedicated, if temporary, night shift, and thus may unnecessarily be walking zombies for a few years.

 

[Playmate2002]

It will be interesting to see how the ACGME will regulate this. In certain programs, first year residents have to work on evenings, weekends and holidays without the supervision of an attending, chief resident or fellow. In my case, I document the cases that were not reviewed by attendings because no attending was present or the attending declined to look at the case with me. In some scenarios, I have held the case overnight because I did not know how to gross it, even when it meant getting yelled at by my attending the next day. Moreover, every case that I review with an attending, I write down sections are expected and the approach to how to gross the specimen. I take this paper and put it in the bucket with the remainder of the specimen.

 

[KCShaw]

In theory, with indirect supervision a supervisor only has to be "available" by phone with the ability to come in if they deem it necessary. I don't know any program that puts residents on duty without faculty at least on-call (even if they're pressured to never call). Programs without such on-call/indirect supervision would appear to be in violation of ACGME standards -- a big one at that, which probably wouldn't go over too well with the local hospital administration or GME office either. Having faculty on call doesn't automatically mean you'll get better help, advice, or training.. but it's something that can be fairly easily tracked. Either someone is documented as on-call with you, or they ain't.

There's still no reason to think direct supervision will be required, certainly not long-term, in the context we're talking about in pathology.

 

[yaah]

68 hour limits? Seriously? What happens when all these people become attending surgeons and don't have work limits anymore?

I don't think these rules would change much of anything in pathology training, personally. No attending is ever going to stand over a resident while they gross routine specimens.

In some scenarios, I have held the case overnight because I did not know how to gross it, even when it meant getting yelled at by my attending the next day. Moreover, every case that I review with an attending, I write down sections are expected and the approach to how to gross the specimen. I take this paper and put it in the bucket with the remainder of the specimen.

Getting yelled at for delaying a specimen by one day to make sure you get it right is much preferable to getting yelled at for screwing up a specimen that you should have asked for help on. Only the insane or clueless would argue that it is always better to just get stuff grossed in.

 

[amygdala_path]

Sorry, did not check back in earlier......

The new ACGME thing about direct supervision is being taken literally. When I said large specimens, I meant non-biopsies. There is serious consideration to have PGY1s only start grossing larger specimens in their second year!! Also there may be no calls for them, since they need to be 'directly supervised' and also due to the '10 hour' rule.

Thanks for all your feedback. I feel better after reading all your thoughts. I thought I was the only one who thought this was ridiculous....

 

[pathstudent]

68 hour limits? Seriously? What happens when all these people become attending surgeons and don't have work limits anymore?

I.

is s

Well it is still 6 twelve hour days. Should be enough time to learn something.

And it is all about patient care. Would you want to go back to the old days when a resident would do your surgery that was working a 72 shift.

An old pathologist told me about how he used to do 36 on and 12 off for a year straight as an intern and he used to perform surgeries without an attending present (basic ones of course like appies and cholies.). That was old school. Is that what we want to go back to. Heck no. Treat interns and medical trainees with humanity. 68 hours a week is more than enough to learn something. I rarely if ever worked more than 68 hours a week in pathology, and I attended probably the most hardcore AP pathology program in the country where residents would often bitch about working 2am-10pm. I didn't believe them as I worked 7am-6pm like a normal person.

 

[amygdala_path]

is s

Well it is still 6 twelve hour days. Should be enough time to learn something.

And it is all about patient care. Would you want to go back to the old days when a resident would do your surgery that was working a 72 shift.

An old pathologist told me about how he used to do 36 on and 12 off for a year straight as an intern and he used to perform surgeries without an attending present (basic ones of course like appies and cholies.). That was old school. Is that what we want to go back to. Heck no. Treat interns and medical trainees with humanity. 68 hours a week is more than enough to learn something. I rarely if ever worked more than 68 hours a week in pathology, and I attended probably the most hardcore AP pathology program in the country where residents would often bitch about working 2am-10pm. I didn't believe them as I worked 7am-6pm like a normal person.

I agree with you that PGY1s should be treated fairly, as I was one not long ago. But not grossing anything for your first year is not to a PGY1's advantage. In fact it is like you would be a PGY1 in your PGY2 year!

 

[pathstudent]

I agree with you that PGY1s should be treated fairly, as I was one not long ago. But not grossing anything for your first year is not to a PGY1's advantage. In fact it is like you would be a PGY1 in your PGY2 year!

True.

 

[Tiki]

The new ACGME thing about direct supervision is being taken literally. When I said large specimens, I meant non-biopsies. There is serious consideration to have PGY1s only start grossing larger specimens in their second year!! Also there may be no calls for them, since they need to be 'directly supervised' and also due to the '10 hour' rule.

What I heard from our ASCP resident rep, is that a senior resident has to be present (in house) while the intern is working, not an attending. So interns will be able to gross, but the senior will most likely have to be somewhere in the hospital while they are doing so.

 

[nebrfan]

Hi guys,
New ACGME requirements are that PGY1 residents are under direct supervision of an attending. What are the changes being made in your program in this regard?
I heard that some programs are considering not having PGY1s gross any large specimens in the first year. Do you think this is acceptable? Please share your thoughts......

So ... NPs (or DNPs, our new colleagues) will be able to practice 'independently' in many states after 2 years of online classes .. but an intern, after 4 years of medical school, needs hand-holding?

More Pathology specific ... our program has decided that no PGY1 can take call ... (so more call for us next year) ... there is talk that attendings will have to be present on weekends while they gross, but I expect that it will be upper-level residents that will have weekends ruined.

They are making PGY1 like a M5 year.

 

[pathstudent]

So ... NPs (or DNPs, our new colleagues) will be able to practice 'independently' in many states after 2 years of online classes .. but an intern, after 4 years of medical school, needs hand-holding?

More Pathology specific ... our program has decided that no PGY1 can take call ... (so more call for us next year) ... there is talk that attendings will have to be present on weekends while they gross, but I expect that it will be upper-level residents that will have weekends ruined.

They are making PGY1 like a M5 year.

How about after hour frozens? Will attendings have to watch interns gross and cut the frozen section. My guess is "yes". That totally sucks.

 

[KCShaw]

I've been struggling to see what everyone is concerned about. As best as I can tell, it relates to the following quote taken from the incoming standards (link in a previous post in this thread):

"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.]"

As far as I can tell from the reading, unless the Review Committee for pathology deems otherwise (why would they? besides, it's up to the program to determine when the described competencies are achieved), once a PGY-1 has received basic grossing training by any supervising physician (could be a senior resident showing them the ropes for a few days/weeks, which is kinda already the norm, right?) then they no longer require direct supervision nor indirect supervision with direct supervision immediately available (i.e., in the hospital) but can be deemed by their program fit for duty with indirect supervision with direct supervision available (i.e., staff on-call by telephone). Or, almost certainly no reason for change unless a program simply hasn't been training its PGY-1's at all, and has just been giving them a book, a bunch of gross buckets, and a threat that it better all be done by Monday AM, and by the way all the staff pathologists will be surfing off Indonesia without a telephone in the meantime.

As a side note, this doesn't have to apply to grossing -- grossing just seems to be the 1 big thing people think about when it comes to pathology residents handling patient care activities, and which can continue after normal working hours. The same could be said about transfusion call, autopsies, etc.

To me it reads pretty innocuous, and clear (when you read other parts of the document as well) that there are lots of ways to supervise other than faculty being in the room or in the building, and that a year doesn't need to pass before a PGY-1 can graduate to less intense supervision. In all honesty, it seems like I'm missing something entirely..? Are there new pathology specific standards which say otherwise..? Or is everyone hyperreacting to nothing..?

 

[nebrfan]

How about after hour frozens? Will attendings have to watch interns gross and cut the frozen section. My guess is "yes". That totally sucks.

In the way we are interpreting it .. yes. Which is why PGY1s will no longer take call (which includes after hour frozens).

 

[2121115]

Will be interesting when intern mistakes are being made by PGY-2's since they will still be, practically speaking, interns. You have to learn at some point, and making mistakes is part of the learning process. You don't get to skip it. You can put it off, but not skip it. At least when you make a mistake as an intern, you can blame it on being a newbie.

 

[PathMD2010]

To my understanding, the main concern is call. More call for PGY-2+ and possibly more weekend grossing (at least sharing weekend days with PGY-1) At least that's what I've picked up from the discussions at my program.

It will suck for those of us taking more call and will delay learning how to do 'on call' things by a year for the incoming PGY-1s but should be doable

The daily activities shouldn't be that different; during normal hours, there is always someone there that you can call to ask a question if needed. That should at least count as 'indirect supervision'

The 68 hr work week could case a few problems as well; while I've never come close to violating the 80 hr rule, there are a few weeks I've worked over 70 - and plenty of days surgery, medicine, and OB residents work over 70 hrs a week.

 

[2121115]

To my understanding, the main concern is call. More call for PGY-2+ and possibly more weekend grossing (at least sharing weekend days with PGY-1) At least that's what I've picked up from the discussions at my program.

It will suck for those of us taking more call and will delay learning how to do 'on call' things by a year for the incoming PGY-1s but should be doable

The daily activities shouldn't be that different; during normal hours, there is always someone there that you can call to ask a question if needed. That should at least count as 'indirect supervision'

The 68 hr work week could case a few problems as well; while I've never come close to violating the 80 hr rule, there are a few weeks I've worked over 70 - and plenty of days surgery, medicine, and OB residents work over 70 hrs a week.

I would have violated a 68 hour workweek many times during residency.

 

[KCShaw]

Where is "68" coming from? That number doesn't exist in the new ACGME common program standards upon a search of the file, and skimming through the duty hours sections I don't see anything like it. As far as having 1 day free from duty including at-home call, that's after being averaged over 4 weeks -- that might affect some programs, I guess, but I don't think it's a change over the existing standards because I remember the same point coming up when I was in residency.

If your program is struggling with something that they think might significantly alter how they do things, urge your PD to contact the pathology review committee. I know people get paranoid about doing so because they think they'll lose accreditation or somesuch nonsense, but it's extremely easy to just say "hey we're reading X here and hearing Y there, does it mean that hypothetically Z would or would not be OK?" They're there to help, not cut your jewels off.

 

[alaska82]

Our program made a lot of changes. PGY1 is supervised by senior level resident while grossing first 2 specimens in each subspeciality rotation. Help is present when ever you need from seniors when you have questions.
Everyday including weekends one of the first years is on call with a senior resident.
The pagers are carried by PGY1 resident.
The frozens during after hours both of them attend. PGY1 does everything and the senior level resident observes and if we cannot cut, they help. Regarding CP calls if we do not know how to respond to the calls we should contact senior level resident.
On weekends PGY1 and the senior level resident both come to review the perpheral smears.
This is good in the sense that we learn a lot. But at the same time tough for the PGY1 resident because we are on call frequently.

 

[HbyHA]

Where is "68" coming from?

heard 68 hrs from from my PD a year or so ago as a possible number the ACGME is considering for the future. right now, it's still 80.

 

[deleted314957]

This thread reminds me of the good old days as a surgical intern in the late 70's. 1 month on the surgical ICU--36 hrs on and 12 off 7 days a week, all month. Married with a wife of 6 months and 2000 miles from "home". ( our 34th anniversary is coming up. Thought you'd be interested LA DOC). Prior to that experience I had seriously considered being a surgeon.

 

[Thrombus]

Maybe this will get some of the oversubsidized academia out of their chairs and doing some real work/teaching (since that is supposedly what they are paid to do).

Unfortunately what will end up happening is it will eventually lead to senior residents (who are supposed to be learning themselves from their academia) being forced to sit and babysit junior residents.

 

[yaah]

We didn't really take call as first years anyway - just autopsies. We were supposed to rotate through all the rotations and get experience before getting call assigned. Since no first years took call it wasn't a burden on anyone.

 

[Euchromatin]

I also don't really understand what the big excitement is about this. It seems that, in most situations, as long as an attending and/or senior resident is available by phone to ask questions (and will come in if necessary) and the PGY-1 has enough knowledge from normal working hours to handle routine stuff, there shouldn't be a any lack of "indirect supervision with direct supervision available."

At my program, first year residents only take AP calls (after hours/weekend frozens, Saturday grossing with a PA, and weekend autopsies). If we get a frozen, the attending has to come in with us anyway to read the slides, so if there is a concern about grossing/cutting/staining it, they are available by phone or we can just wait a few more minutes for them to arrive. The attending on call also has to come in on Saturday morning to sign out micros, so they're in the building for any grossing or Saturday autopsy questions. If we get an autopsy late on Saturday or on Sunday, it is at the attending's discretion if they want to come in or we save the organs and they look at it early Monday morning.

 

[lipomas]

So first year of residency is basically going to be turned into 4th year of med school? Shorter hours, no real responsibilities? Just eliminate 4th year then!

 

[2121115]

Mistakes will happen the first time a trainee encounters something. PGY-1 or PGY-2 doesn't matter.

 

[amygdala_path]

I agree that people are overreacting. But PGY1s will not take call, nor gross anything but biopsies nor perform an autopsy. So pretty soon, something is going to go wrong in a PGY2 year and there is going to be a new policy stating that PGY2s need supervision.😕
Does anyone know how the other specialties are handling this?

 

[KCShaw]

I doubt many programs have any need to change, pathology or otherwise, except to possibly document PGY-1's achieving certain competencies before being cut loose.

The new standards allow PGY-1's to take call, gross, perform autopsies, and work alone in the hospital after hours with a senior/attending available off-site to answer the phone for them (there is always at least 1 surgical, medical, path, radiology, etc. attending/fellow on call for emergencies -somewhere- for any tertiary institution), once their program deems them capable of doing so by way of demonstrating competency (generally subjective opinion) in anything specific their specialty review committee may list for them. Nothing says that has to be arduous or take long to accomplish. Only prior to that does a senior/attending need to be in the hospital or otherwise "immediately available for direct supervision."

 

[deleted314957]

Mistakes will happen the first time a trainee encounters something. PGY-1 or PGY-2 doesn't matter.

The "system" should understand that mistakes will be made through one's professional lifetime ( hopefully they are few and of little consequence) and just suck it up. The apron strings have to be cut at some time.

 

[zao275]

This thread reminds me of the good old days as a surgical intern in the late 70's. 1 month on the surgical ICU--36 hrs on and 12 off 7 days a week, all month. Married with a wife of 6 months and 2000 miles from "home". ( our 34th anniversary is coming up. Thought you'd be interested LA DOC). Prior to that experience I had seriously considered being a surgeon.

Congrats to you guys! Yes, I loved surgery but the hours are not for me. Fortunately, I truly loved path more. I actually entered med school wanting to do path.

BTW, the Residents Forum has an Action Group looking into the new ACGME regs and they have been in communication with some of the people involved in these new rules. Nothing official, of course, but an attempt to discern what all of the rules will mean. Their findings are posted on the path wiki: http://pathinfo.wikia.com/wiki/ACGME_Duty_Hours.

Jerad

 

[Tiki]

The first years not being able to take call past 10:30 is absolutely ridiculous. Why don't they just put them back in medical school for an extra year.

 

[Doctor Bagel]

I doubt many programs have any need to change, pathology or otherwise, except to possibly document PGY-1's achieving certain competencies before being cut loose.

The new standards allow PGY-1's to take call, gross, perform autopsies, and work alone in the hospital after hours with a senior/attending available off-site to answer the phone for them (there is always at least 1 surgical, medical, path, radiology, etc. attending/fellow on call for emergencies -somewhere- for any tertiary institution), once their program deems them capable of doing so by way of demonstrating competency (generally subjective opinion) in anything specific their specialty review committee may list for them. Nothing says that has to be arduous or take long to accomplish. Only prior to that does a senior/attending need to be in the hospital or otherwise "immediately available for direct supervision."

I don't know about pathology, but I think you're mistaken about supervision for first years. My understanding is that supervision has to onsite for the whole year. It can be indirect once someone has achieved a certain level of proficiency, but indirect apparently still means someone can be immediately available, so it's still inhouse.

In my specialty, we routinely get supervision through calling attendings at home, and that's not going to be OK for first years next year here.

 

[KCShaw]

The levels of supervision are defined in the standards, summarized as:

1. Direct (present in the room)
2. Indirect with direct immediately available (in-house)
3. Indirect with direct available (on-call)
4. Oversight (after the fact, what the resident did can be reviewed)

(For some reason "oversight" isn't applied again in the standards, except to define it and say programs should use it as a classification of supervision, presumably in how they internally structure graduated responsibility.)

The issues seem to be with people not understanding the difference, and when one or another can/can't be applied. Importantly, there are two levels of "indirect" supervision, which I have as #2 and #3, and they are dramatically different in practical application. From my review, brand new PGY-1's require #1 or #2, and can progress to #3 by achieving competencies (which may be programmatic, or may be specified by the review committee). There is nothing that says achieving those competencies has to be arduous or take a long time, unless the review committee specifies otherwise.

 

[Doctor Bagel]

Just read over it, and it looks like this is the key provision for PGY1s --

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.]

To me, that reads as if PGY1s are going to need inhouse supervision the whole year. I agree that that sentence in parentheses is a little confusing, but I think it means that the RC will decide when a resident can move from direct supervision to indirect supervision with direct supervision immediately available. Telephonic and electronic supervision are the next level down, which it not going to be allowed for PGY1s.

 

[Ruination]

Unfortunately what will end up happening is it will eventually lead to senior residents (who are supposed to be learning themselves from their academia) being forced to sit and babysit junior residents.

Been happening at my program for 4+ years already.

 

[TMZ2007]

It seems our PD is interpreting this to say PGY1s can only gross on weekends when a more senior resident is also present, so now all the senior residents get to double up weekends next year. 🙁

 

[KCShaw]

In the recent quote from the standards, the word "immediately" does not exist in the bracketed portion at the end. Please don't insert it nor assume that it is there. It is the key word differentiating the two categories of indirect supervision -- "immediately" basically meaning in-house coverage, while dropping that word also drops the in-house requirement. In other words, within that one quote, three categories of supervision are mentioned..not two with one of them twice.

Otherwise yes, I think that is the quote most people are stomping around about. But it still comes down to the pathology RC, which does not officially meet until April. Unfortunately, of course, that means programs trying to schedule for this coming July are a little stuck; however, they really, really should hold off as much as possible until the RC has had their say. The RC could very, very easily handle this without much fuss.

 

[icpshootyz]

Otherwise yes, I think that is the quote most people are stomping around about. But it still comes down to the pathology RC, which does not officially meet until April. Unfortunately, of course, that means programs trying to schedule for this coming July are a little stuck; however, they really, really should hold off as much as possible until the RC has had their say. The RC could very, very easily handle this without much fuss.

Exactly. There's a lot of fuss over nothing until we have something official. As of right now, it's just potential. But think about what we do in path compared to our clinical colleagues, and I think that this rule won't apply to path at all. After hour frozens? There's always an attending for those since only attendings (and maybe fellows at some programs) can sign-out a frozen diagnosis. So no change there. Weekend autopsies? Patient's dead, not exactly a big concern if you cut them up slightly wrong. A little crass, but think about why this rule is being implemented - they don't want interns killing patients. We don't kill patients. We get dead ones. As for weekend grossing, technically there's always an attending on call to answer questions, and really that's all that you need as a weekend grossing resident. You don't need to have your hand held for every tiny thing. Have a question? Call. If you don't know how to gross something on the weekend, call. And if you STILL don't know, fix it and have someone help you on Monday.

I really don't see this being any issue at all for Pathology.

 

[lurksalot]

Exactly. There's a lot of fuss over nothing until we have something official. As of right now, it's just potential. But think about what we do in path compared to our clinical colleagues, and I think that this rule won't apply to path at all. After hour frozens? There's always an attending for those since only attendings (and maybe fellows at some programs) can sign-out a frozen diagnosis. So no change there. Weekend autopsies? Patient's dead, not exactly a big concern if you cut them up slightly wrong. A little crass, but think about why this rule is being implemented - they don't want interns killing patients. We don't kill patients. We get dead ones. As for weekend grossing, technically there's always an attending on call to answer questions, and really that's all that you need as a weekend grossing resident. You don't need to have your hand held for every tiny thing. Have a question? Call. If you don't know how to gross something on the weekend, call. And if you STILL don't know, fix it and have someone help you on Monday.

I really don't see this being any issue at all for Pathology.

The problem for pathology exists if the ACGME forces across-the-board restrictions. Yes, these new regulations are basically to prevent abuse and errors in specialties like IM and surgery, but if applied to pathology, will necessitate some changes.

I disagree with you about call and autopsies not being an issue. Programs do exist where senior residents are diagnosing after-hours frozens (they don't bill, which is how these programs can do this).

Make no mistake- pathologists CAN kill patients if errors in grossing and diagnosis are made. I've noticed a trend in which path residents don't seem to take grossing as seriously or think that it's an important part of training. Believe me, if you miss a lesion, take the wrong section, measure a tumor or margin incorrectly- it can have an impact on patient management and prognosis.

Some programs don't always have dieners available on weekends- believe me, funeral home directors and families DO care if the dissection was sloppy.

 

[icpshootyz]

I agree that there are times where supervision is definitely necessary, but you're giving examples of programs that I feel should be reprimanded anyways. A diener should be available for all autopsies, frozens should always be attended by an attending (or at least fellow), and like I said, any specimen that someone is worried about could be fixed and held until a senior or attending could assist with grossing. And as others have pointed out, errors could occur at any level of training. At my program we have particular protocols in place to train first years - July is a full month of progressive training starting with shadowing and ending w/ supervised grossing, as well as basic autopsy techniques, frozen section instruction, and general orientation. For the entire year all tumor resections are mandated to be shown to a fellow for proper grossing instruction and triage. Surgpath fellows attend almost all frozen sections both to provide assistance and to learn themselves. Yes, 1st years do all the AP call starting in August, but their first week of call is with in-house senior resident backup support. Extending senior resident backup the entire year would be overkill, and I doubt seniors would stay in-house anyways (just like attendings don't stay in-house). We'll see, but I don't think ACGME will make sweeping, all-specialty regulations.

 

[Pianoboe01]

I think it's ridiculous PGY-1's are not allowed to take at home call:

"Question: Can PGY-1 residents take at-home call, and if so what are the work-hour restrictions for this? Answer: PGY-1 residents are limited to a 16-hour shift and are not allowed to take at-home call. Note: a shift can be defined as 7:30 AM to 11:30 PM."

 

[brainsalads]

Everyone seems to be focusing on AP call, which is a cakewalk compared with CP all at my institution. CP call covers blood bank, apheresis, and all lab medicine. We take it in week blocks, and it is home call. Now, that doesnt mean you wont be up all night taking calls. The thing is, PGY1 take 36 weeks of CP a year. According to the new rules home call for PGY1 is not allowed. So basically they will not take call and all those weeks will get dumped on the 2, 3, and 4 years, with the brunt going to 2nd years. This is just a set up for second years in the future being unprepared and less experienced. ACGME didnt even think of pathology when they came up with these rules.

 

[schrute]

Though I can't imagine how steamed most other specialties are RE call being dumped on 2nd, 3rd, 4th, etc, years, the fact remains that pathology is the single solitary exception to the "PGY1" notion. IE: PGY1 path is not an intern year...it's PGY1 pathology. Approaching the 80-hour work week is (on a national average) more of the exception than the rule; 16-hour work shifts are more of the exception than the rule.

Does anyone in our leadership have any stones? Does everyone wear Shape-Ups and just roll over every time the ACGME, et al bureaucracies made up of out-of-touch clinicians & litigious-minded lawyers, makes some ridiculous requirement?

Good God, I'm so sick of this crap I'm now 90% certain that I'm going to do leave medicine within 5 years, 1 if I win the lottery.

"You younger generation docs are all greedy...you don't want to work hard...you're not committed to the practice of medicine..."
--More or less. Because pay has only gotten worse (relatively speaking), the work has gotten infinitely more complicated, and your avg physician--GP or whatever--doesn't practice 'medicine'...he/she practices whatever insurance companines & hospital administrations dictate.

[gets off soapbox and takes a xanax]