"Protected Time" in residency... does it happen for you?

[fiatslug]

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Due to a variety of reasons--small program (4/yr), increased pressure to keep the inpt psych census full, closing of other local inpt units--we've had a particularly rough time this year (the R2 year) with what is supposed to be protected time for supervision (psychotherapy, inpt, caseload). Apparently the RRC has very strict requirements about supervision, and we haven't been able to do it. The faculty is just getting a sense of this now--we've known all along, but haven't articulated our complaints well until now--but it seems no matter which way you slice it, it's virtually impossible to protect supervision time for our 2s. As a result, we just kind of slog through the day, trying to get through work, and teaching has been marginalized--something none of us, faculty or residents, are happy about. The problem is at last being acknowledged by everyone; unfortunately, solutions are slim (but oh, wouldn't we love a 5th or 6th resident!). This is really, fundamentally an issue for 2s (and to a lesser extent the onesies, though they have much fewer demands on their time)--3s & 4s are all outpt. Because our supervision times aren't protected, and other responsibilities (daytime ED coverage, insanity on the unit, etc) can easily become more acute, supervision gets the short shrift. Just wondering how other residencies manage this problem, if it's been a problem where you are at all.

 

[Anasazi23]

We have a senior coordinator, who is doing the "inpatient coordinator" rotation cover for the PGY-1's and 2's. They carry all the beepers, or notify the services (ER, etc) that they should be paged for the next X number of hours. The seniors aren't too keen on this, but there was really no other suitable way.

 

[whopper]

I'm in UMDNJ-Camden. There are 2 groups. 1 group is stationed in Camden, the other in Atlantic City. The Atlantic City residents do get protected time. The Camden residents tell me their time is not protected, but since I do not work in their hospital, I don't know how much and how bad the situation is for them.

 

[Doc Samson]

Due to a variety of reasons--small program (4/yr), increased pressure to keep the inpt psych census full, closing of other local inpt units--we've had a particularly rough time this year (the R2 year) with what is supposed to be protected time for supervision (psychotherapy, inpt, caseload). Apparently the RRC has very strict requirements about supervision, and we haven't been able to do it. The faculty is just getting a sense of this now--we've known all along, but haven't articulated our complaints well until now--but it seems no matter which way you slice it, it's virtually impossible to protect supervision time for our 2s. As a result, we just kind of slog through the day, trying to get through work, and teaching has been marginalized--something none of us, faculty or residents, are happy about. The problem is at last being acknowledged by everyone; unfortunately, solutions are slim (but oh, wouldn't we love a 5th or 6th resident!). This is really, fundamentally an issue for 2s (and to a lesser extent the onesies, though they have much fewer demands on their time)--3s & 4s are all outpt. Because our supervision times aren't protected, and other responsibilities (daytime ED coverage, insanity on the unit, etc) can easily become more acute, supervision gets the short shrift. Just wondering how other residencies manage this problem, if it's been a problem where you are at all.

You're seeing outpatients without regular supervision? Holy lawsuit, Batman!

 

[fiatslug]

You're seeing outpatients without regular supervision? Holy lawsuit, Batman!

😳
We're seeing them with irregular supervision, at times. I've had to miss probably 5 or 6 of my weekly supervision meetings this year b/c of being on call in the ER and getting crushed--unfortunately we don't have sr resident back up for our (un)protected time. As a soon to be 3rd year, I certainly understand not wanting to do it! Have you ever heard of residencies hiring staff to cover the ER during the day, or is that just wishful-bordering-on-delusional thinking?

Looking forward to my last day as daytime ED scut biatch,
Slug out.

 

[MBK2003]

Our ER volume increased so dramatically over the past 5 years that they changed the responsibility of the ER attendings from "supervising the PGY-3s" to actually requiring them to see the patients and less about the supervision, so the pendulum has completely swung the other way in the setting of a crushing workload, and our supervision time in the ER has disappeared with our didactic time completely protected. They've also hired more attendings on the weekdays, but the process was slow. Our supervision time on the inpatient units and in the outpt clinics is still strictly protected, but we have a much larger residency, and our ER coverage is scheduled - e.g. I know that the same one day every week in PGY-3 I'm in the ER all day, so I don't schedule anything for that day.

Unpredictability in volume is a horrible thing to deal with - that's why our C/L service rotation (4 months 😱 ) is such a pain in the a$$, you are trying to schedule outpatients, supervisors, and class, when BAM... an emergent consult gets called in.

MBK2003

 

[Doc Samson]

😳
We're seeing them with irregular supervision, at times. I've had to miss probably 5 or 6 of my weekly supervision meetings this year b/c of being on call in the ER and getting crushed--unfortunately we don't have sr resident back up for our (un)protected time. As a soon to be 3rd year, I certainly understand not wanting to do it! Have you ever heard of residencies hiring staff to cover the ER during the day, or is that just wishful-bordering-on-delusional thinking?

Looking forward to my last day as daytime ED scut biatch,
Slug out.

We have clinical nurse specialists covering most of the ED workload during the day. Our pgy-2 residents are completely excused from their services (ED or inpatient) every Wednesday to see outpatients/go to supervision/attend didactics. That time is completely and utterly protected.

Likewise, for CL in the 3rd year, we have a shift system... everyone works either 9am-2pm or 1pm-6pm every day, with the rest of the time dedicated to outpatient work, supervision, didactics, research, whatever. If a call comes in at the end of a shift, it gets carried over to the next group.

Residents missing supervision would be regarded as a cause for serious concern.

 

[fiatslug]

We have clinical nurse specialists covering most of the ED workload during the day. Our pgy-2 residents are completely excused from their services (ED or inpatient) every Wednesday to see outpatients/go to supervision/attend didactics. That time is completely and utterly protected.

That sounds like fairy godmother talk! I love it! However I seriously doubt we'd have the budget for it... 🙄 unless we are told to "Make It So" by the RRC. I wonder what would be harder: getting funding for extra residents from Medicare or getting funding for a clinical nurse specialist to cover the ED during the day??

Likewise, for CL in the 3rd year, we have a shift system... everyone works either 9am-2pm or 1pm-6pm every day, with the rest of the time dedicated to outpatient work, supervision, didactics, research, whatever. If a call comes in at the end of a shift, it gets carried over to the next group.

Residents missing supervision would be regarded as a cause for serious concern.

We do C/L in the 2nd year; 3rd year is all outpt. A couple of years ago, they had 3rd years covering the ED during the day, and it was disastrous--then it got shifted to the 2s, which worked until our inpt census essentially doubled.

 

[outofhere]

I guess my experience has been the exception. I meet with my two psychotherapy supervisors weekly, then I have another hour for medication supervision, all this for my continuity clinic. Then, for my other rotation, I have yet another supervisor- so it adds up to four hours a week in supervision. I will surely miss this when I finish shortly. Our didatic time is also supposed to be protected- it is more protected in PGY 3 and 4, but less so in 2. All in all, I have found my experience more than satisfactory.

 

[Doc Samson]

We do C/L in the 2nd year; 3rd year is all outpt. A couple of years ago, they had 3rd years covering the ED during the day, and it was disastrous--then it got shifted to the 2s, which worked until our inpt census essentially doubled.

The APM has recommended, and the RRC is about to insist, that the CL experience occur in the PGY-3 or 4 year, since a large part of the job is convincing other services that you know your stuff, and this is difficult for PGY-2s since they are still so new to psychiatry.

The ACGME regularly visits both individual training programs and training institutions (i.e. both the psychiatry residency and the hospital in which it's based) to accredit them - somewhere between every 2-4 years depending on how good things looked last time around. They are required to talk to residents for at least an hour without any admin/attendings present when they're there. If your PD isn't anxious about your accreditation, you should be. 4 years at non-accredited residency is worth squat. If a program loses accreditation (though they usually get a 1 year probation to fix the problems first), the current residents have to scramble for open slots in programs elsewhere.

 

[littlepurplepil]

The APM has recommended, and the RRC is about to insist, that the CL experience occur in the PGY-3 or 4 year, since a large part of the job is convincing other services that you know your stuff, and this is difficult for PGY-2s since they are still so new to psychiatry.

The ACGME regularly visits both individual training programs and training institutions (i.e. both the psychiatry residency and the hospital in which it's based) to accredit them - somewhere between every 2-4 years depending on how good things looked last time around. They are required to talk to residents for at least an hour without any admin/attendings present when they're there. If your PD isn't anxious about your accreditation, you should be. 4 years at non-accredited residency is worth squat. If a program loses accreditation (though they usually get a 1 year probation to fix the problems first), the current residents have to scramble for open slots in programs elsewhere.

If C/L is moved to the PGY-4 year, wouldn't this inhibit (or prohibit) people that want to do the early match into Child psych?

 

[Doc Samson]

If C/L is moved to the PGY-4 year, wouldn't this inhibit (or prohibit) people that want to do the early match into Child psych?

Most programs would put it in the 3 year, but there are already programs that deliberately put required rotations in the 4 year so that they can hold on to their manpower.

 

[littlepurplepil]

Most programs would put it in the 3 year, but there are already programs that deliberately put required rotations in the 4 year so that they can hold on to their manpower.

Bah! Name names & expose these evildoers so I know where not to apply! 😛

 

[Doc Samson]

Bah! Name names & expose these evildoers so I know where not to apply! 😛

Don't have to name names, just look at the curriculum. Any program that schedules any nonelective rotation in the 4th year other than outpatient.