Outpatient hours violation

[buddy 2004]

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Hello, I was looking over the ACGME requirements for PM&R
(http://www.acgme.org/acWebsite/downloads/RRC_progReq/340pr706.pdf)
and noticed the following line:

"Residents must spend at least 12 months of their training in the care of
outpatients. This outpatient experience must include significant experience
in the care of patients withmusculoskeletal disorders, and it excludes time
spent in EMG training."

At some program, including mine, the EMG rotation (4 months) supposedly contributes to the outpatient time, and without this our program is in violation of these ACGME rules. What is the best way to go about pressuring my program into getting more outpatient time? Would contacting the ACGME directly to report this violation be seen as a hostile act and get me thrown out of the program? We just got recredentialed last year, but I was not aware of this EMG exclusion and it was not mentioned at the time.

Thanks.

 

[mdvol]

I would think you would talk to your chief(s), program director or chair if you had good rapport - instead of calling in the big guns of the ACGME. We don't count EMG for outpatient at UVA and the chiefs are involved with program enough to know how many hours residents have on which rotations.

 

[axm397]

Hello, I was looking over the ACGME requirements for PM&R
(http://www.acgme.org/acWebsite/downloads/RRC_progReq/340pr706.pdf)
and noticed the following line:

"Residents must spend at least 12 months of their training in the care of
outpatients. This outpatient experience must include significant experience
in the care of patients withmusculoskeletal disorders, and it excludes time
spent in EMG training."

At some program, including mine, the EMG rotation (4 months) supposedly contributes to the outpatient time, and without this our program is in violation of these ACGME rules. What is the best way to go about pressuring my program into getting more outpatient time? Would contacting the ACGME directly to report this violation be seen as a hostile act and get me thrown out of the program? We just got recredentialed last year, but I was not aware of this EMG exclusion and it was not mentioned at the time.

Thanks.

We don't count EMG months or consult months. I don't think going to the ACGME will be a good idea. Do you have any way to anonymously raise concerns? At my program we have a residency wide meeting with the PD twice a year with anonymous questions and concerns solicited before the meeting by the chiefs. (drop them off in a box in their office or email them).

 

[lobelsteve]

Become the chief resident, the president of your housestaff, an RPC regional representative, Chairperson for your state medical society resident and fellow section.........and then start asking for things to be done appropriately.

If you make a big enough stink at just the right time (during an RRC visit), you may: get arbitrarily harrassed, accused, denigrated, penalized, and everything short of put on probation or fired by your department.

If you are slick 😎 , have lunch with David Leach in Hawaii (or wherever your AMA annual meeting is as you must go as a delegate to cast your states vote on matters as the Chairperson for your states medical society) and talk to a good clinical psychological strategist (thanks Sandy)....

you may get your diploma, a crappy silver cup, your program director loses her job, your department chair stays but has no political capital at the institution, the remaining staff in the department bail out of town (though most left in the months leading up to this).


Bottom line: shut up and serve your time. Beg me for an interview and I'll take pity and get you a seat in front of the man. That is if you have an interest in Pain.

Me bitter? No! (sarcasm)

 

[drusso]

EMG does NOT count as outpatient experience and I know this from previous similarly related issues.

You have every right to demand the best training. I would agitate for change. 😀

 

[paz5559]

EMG does NOT count as outpatient experience and I know this from previous similarly related issues.

You have every right to demand the best training. I would agitate for change. 😀

Please take drusso's "agitate" with a grain of salt - he is an extraordinary politician, and is one of the few who can accomplish such a feat without ticking the powers that be off.

 

[rehab_sports_dr]

In matters re: changing the construction of your residency, I think it is a HUGE mistake to go right to the accreditting agency. Since your goal is to constructively improve your program, your discussion should be with those people who have the power to initiate the change internally.

changing the rotation schedules is a non-trivial process. It is not simply a matter of the chair and PD saying "we would like more outpatient months" and instantly having it.

Some issues that also have to be addressed:
1. Havng enough clinical staff to support the residents
2. Having suffecient patient volume for the clinical staff and residents
3. Funding for the residents at each of these rotations
4. Funding of malpractice at each of the rotations
5. Making sure that the other requirements continue to be met by including more outpatient (i.e., the time has to come from somewhere else).

These changes take time. The easy thing for a department to do is to simply hire somebody because they want to get the outpatient capacity. The wiser thing is for a department to make sure they are hiring the right person.

So, I strongly suggest working with the people who have your best interests in mind, instead of starting an adversarial relationship that is likely to antagonize the very people who are trying to help you.

 

[buddy 2004]

So, I strongly suggest working with the people who have your best interests in mind, instead of starting an adversarial relationship that is likely to antagonize the very people who are trying to help you.[/QUOTE]

Actually, the people who have our best interest in mind are the residents including myself who are complaining. Until our review last year, we had only 4 months of outpatient time and some "exagerations" had to be made to claim that we have 12 months of outpatient time. For example, on our inpatient months it was claimed that we spent 20-25% of our time in outpatient clinic, which was not the case.

I would not be starting an adversarial relationship because one already exists between our program director and the residents. Although this is a training program, the residents do not come first and education is not a priority. The resident's primary job is to "cover" the inpatient services, which always take priority. There is no funded position strictly for non-inpatient training.

Using the term outpatient is a blunt instrument. We did have outpatient months added, but they were simply additional clinic hours with the same two attendings seeing the same patients. There is no educational variety (a conceit of the program director, I suspect, since he seems insulted when we mention that we would like different experiences aside from his clinic). We were invited by our local O&P vedor to spend time in their facility every week, but the suggestion was quickly disregarded since the program director felt that there was no direct supervising physician and the education would be poor (yes, we can't learn from a prosthetist, we need a physician). The program director's latest suggestion is starting up a (inpatient) cardiopulmonary rehab rotation at our main inpatient site, including taking inhouse call on Saturday from 7a-7a Sunday (!). We suggested that this was an increasingly minor component of the physiatry field and it was met with hostility - that we were rejecting his suggestions outright while constantly complaining of wanting more rotations.

So, my point is that this program is headed in the wrong direction, and I am trying to change it for the better. I could very well name the program for everyone to see and cause them not to have any residents at all for the next couple of years, but then the program would be stuck with only the most desperate residents who would just do whatever rotations were given to them with less complaining.

Thanks for the advice, I would love to hear more...

 

[dc2md]

i applaud this guy/girl for making an effort to change this program for the better. i'm currently matching this year into PM&R and i'm glad people like him/her are out there. i really hope this isn't a program i'm considering...it doesn't sound like it though. best of luck with all this "buddy".👍 👍

 

[lobelsteve]

i applaud this guy/girl for making an effort to change this program for the better. i'm currently matching this year into PM&R and i'm glad people like him/her are out there. i really hope this isn't a program i'm considering...it doesn't sound like it though. best of luck with all this "buddy".👍 👍

I think I warned you in another thread about a certain program.....

In 3 short years, you cannot change a program that does not already want to change. If they give you 4 months, it is likely because it fits teir needs. Your needs are secondary and your concerns are not their concerns.
Bite your tongue and serve your time. If you rock the boat, prepare to be drowned.

Yes, I'm slowly working on the manuscript for the story I've been telling. It's progressing slowly. Too busy working and living to write too much...

 

[buddy 2004]

Thanks for your candor about this issue. Yes, I respect the program for taking me in when others did not, and I am grateful. But I am always looking for ways to improve, if not for me then other residents in the future.

I think this is an average program, and I am certainly trying to extract what I need from it and then move on to fellowship hopefully. It is a good thing that fellowships are only one year, too, or else I might find myself in th same situation.

Still, I wonder if being totally honest is bad overall, since medical students will get a bad impression and spread the word about it. Is no residency program better than a substandard one?

 

[lobelsteve]

Is no residency program better than a substandard one?

Is a doctor trained at the worst program still a qualified physician?
The validation comes from the boards, and that comes from $$$$$ not skill or necessarily brains. Even I passed!

If I were a patient, I'd skip the doc that trained at the worst program. Of course patients do not know these things and if my waiting room has a plasma TV, then I must be the best doc in the world.

 

[Disciple]

We were invited by our local O&P vedor to spend time in their facility every week, but the suggestion was quickly disregarded since the program director felt that there was no direct supervising physician and the education would be poor (yes, we can't learn from a prosthetist, we need a physician). The program director's latest suggestion is starting up a (inpatient) cardiopulmonary rehab rotation at our main inpatient site, including taking inhouse call on Saturday from 7a-7a Sunday (!). We suggested that this was an increasingly minor component of the physiatry field and it was met with hostility - that we were rejecting his suggestions outright while constantly complaining of wanting more rotations.

Wow, if I were a resident at your program, I don't think I would be a big fan of your program director.

During residency I spent 2 months working 1 on 1 with O&P guys. Who better to learn about this stuff than from someone who does it all day long?

The suggestion about the cardiac rehab rotation, not only does that not help you, but it makes things substantially worse. Physiatrists are rarely involved in hospital cardiac rehab programs anymore.

I agree that you probably shouldn't make too big of a stink about this. Remember, your PD has to write you a summary evaluation when you graduate. However, if you think this may ruin your training oppotunity (which it sounds like it very well may), you may want to start calling up programs to see if there are any openings.

I think I've said this before, but you definitely do not want to count on using a 1 year fellowship to remediate poor training from residency.

 

[Disciple]

I think I warned you in another thread about a certain program.....

In 3 short years, you cannot change a program that does not already want to change. If they give you 4 months, it is likely because it fits teir needs. Your needs are secondary and your concerns are not their concerns.
Bite your tongue and serve your time. If you rock the boat, prepare to be drowned.

Yes, I'm slowly working on the manuscript for the story I've been telling. It's progressing slowly. Too busy working and living to write too much...

Publish it in the new AAPM&R journal. I'll be looking forward to reading it.

 

[buddy 2004]

So, we did a little recon on the supposed ACGME violation, and the PD was aware of the rule. He said that his calculation for outpatient time did not include the EMG training. Instead, the 12 months of time were cobbled together from the inpatient services, where he somehow thinks that 25% of our time is spent in outpatient clinics. When added together from our 20 months of inpatient service, this somewhow makes 12 months. Of course, I disagree with that calculation. Of the inpatient services that may have a clinic, this is at most half day. (about 10% of a week month block). I suppose many other programs do this as well.

 

[axm397]

So, we did a little recon on the supposed ACGME violation, and the PD was aware of the rule. He said that his calculation for outpatient time did not include the EMG training. Instead, the 12 months of time were cobbled together from the inpatient services, where he somehow thinks that 25% of our time is spent in outpatient clinics. When added together from our 20 months of inpatient service, this somewhow makes 12 months. Of course, I disagree with that calculation. Of the inpatient services that may have a clinic, this is at most half day. (about 10% of a week month block). I suppose many other programs do this as well.

It could be that the number of inpatient patients you carry is not sufficient to meet ACGME requirement to call it "100% inpatient". (need at least 8 patients per resident). Also, if you are doing any consultations (inpatient) while doing an "inpatient" service - that time doesn't count.

We have continuity clinic 1 half day a week - so that's 10% of our time - counts as outpatient. We also do NOT have clinic our first 6 months AND we are expected to go to at least 4 half day clinics a week on Pediatrics (which counts as 50% inpatient although we carry avg 12 pts on Peds). It's a complicated calculation but although it feels like a lot of inpatient, we just make the 12months required of both inpatient and outpatient. (Need to subtract vacations/holidays too.)

 

[rehab_sports_dr]

I would again strongly caution you against taking an aggressive action against your program.

Your goal, as best I can tell, is to increase your personal exposure to outpatient medicine. The action of reporting your program is unlikely to achieve that goal. It is also unlikely to benefit future residents, since they may slap something together to call it "outpatient" without really remidiating the deficit in your training.

First off, as stated before, the process of changing rotations (and securing funding and insurance for each of those rotations) is a non-trivial process. Often the arrangments for rotations are made years in advance, and there are contracts in place. It's not as simple as "Johnny wants more outpatient exposure, so POOF, we have more outpatient exposure."

Second, you want to build clinical capacity the right way. It takes time to hire the right person. In truth, you don't just want outpatient exposure. You want QUALITY outpatient exposure.

Third, you may not be aware of all of the details of the calculations involved.

Forth, you may not appreciate the value of some of the clinical rotations you currently have. For example, I too was very dismissive of my cardiac rotation before I had it, but it turned out to be one of my best experiences as a resident.

Fifth, reporting your residency to auditing boards can hamstring your program in a way that makes it more difficult to make improvements in the future.

In general, complaining and developing antagonistic relationships with colleagues is not a fruitful way to produce change.

If your goal is simply to get more outpatient exposure for yourself, see if you can work out some mechanism to get some elective time at another program.

If your goal is to improve MSK training at the program in general, work with them to come up with creative ways to build up clinical capacity while still securing funding and insurance. Examples would be agreeing to do extra call on the outpatient rotation to cover your costs, while working in a local outpatient MSK doc (who doesn't neccessarily have to be a physiatrist) to obtain the needed clinical experience.

 

[drusso]

Please take drusso's "agitate" with a grain of salt - he is an extraordinary politician, and is one of the few who can accomplish such a feat without ticking the powers that be off.

Okay, here's better advice:

"Agitate" but don't shoot yourself in the foot. Sitting down with program director and discussing your concerns is a good place to start. Letting them know that you're doing "re-con" work is reasonable too. Comparing and constrasting your program with other "peer institutions" is powerful ammunition. Telling them that you've read the ACGME requirements is non-threatening and demonstrates an interest in your education. Ask them to EXPLAIN things to you so you can better understand WHY your program is structured the way it is. Ask them to demontrate HOW they believe that the structure of the program meets fits with the department's vision of what an ideally trained physiatrist looks like, the state of the art of the field, and the direction the specialty is going. Ideally, the PD should be doing this on interview day for all new applicants.

Remember: One of the six ACGME "core competencies" is "systems-based practice." It seems to me you're just trying to become competent in understanding the rules that govern the system...your efforts should be applauded.

Agitating is not the same as alienating. Stirring things up and facing new information is often uncomfortable for people--especially those who think that they know more than you--but usually a little agitation is exactly what is needed to get from point A to point B. Though you are in training; you are an adult and so are your trainers. You don't have to accept everything they tell you "just because." That works when you're six, but not 26.

Check out the book "Crucial Conversations." I highly recommend it.

 

[lobelsteve]

Publish it in the new AAPM&R journal. I'll be looking forward to reading it.

I'm an MD. Maybe if I was a PhD, PT, MSc, MSN I could publish in an AAPMR journal.

I'm thinking book.