Studying for ABPM Cert

[Adam Smasher]

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Is there any oversight or way to look at a programs volume of surgical cases versus number of residents and say you only qualify for x number of spots based on your production. I get there's a minimum requirement of cases and diversity in cases which should kind of dictate that but the minimum requirement is laughably low. It would decrease the number of resident slots, absolutely, but would lead to better training and decrease some of this first/second assist nonsense with multiple residents scrubbing cases.

Problem is when a hospital definitely wants residents to amputate all the infected toes but they may not have the volume/diversity to train people on trauma or even bunions. part of the auditing process is making sure the program adheres to ACGME standards, and ACGME standards in turn dictate caps on duty hours. And yeah I know we all lied about our duty hours, but this is a discussion about rules and accreditation so there's that. If the hospital is a frequent stopover for the pusbus, they'll want extra residents just to handle the pager/floor work that comes with it.

Another issue is that the more residents the program takes on, the more GME funding they get, so a lot of program directors are under pressure to take on additional residents just for that reason. Just another example of how what's good for podiatry is often bad for podiatrists.

 

[Homo sapien]

You can't double log a first assist in a procedure in PRR.

If you make up surgeries ... I don't know what to say.

Programs do do that. Plenty programs are really that bad. Some programs people are logging first assists being the only resident BUT the attending doesn't let them do any of the case. So they got the first assist but not the surgical experience.

But if the option is report your ****ty program and blow it up vs not be able to have a career, I know what most will pick

 

[Sendin_Toes_2market]

Programs do do that. Plenty programs are really that bad. Some programs people are logging first assists being the only resident BUT the attending doesn't let them do any of the case. So they got the first assist but not the surgical experience.

But if the option is report your ****ty program and blow it up vs not be able to have a career, I know what most will pick

Residency programs weaponize HR and GME. It’s easier to remediate and scare a resident then it is to fire a 75-90+ percentile producing director and hire a new one.

I heard horror story from other residents. I chose to keep my mouth shut.

 

[Bluecollarmed]

Problem is when a hospital definitely wants residents to amputate all the infected toes but they may not have the volume/diversity to train people on trauma or even bunions. part of the auditing process is making sure the program adheres to ACGME standards, and ACGME standards in turn dictate caps on duty hours. And yeah I know we all lied about our duty hours, but this is a discussion about rules and accreditation so there's that. If the hospital is a frequent stopover for the pusbus, they'll want extra residents just to handle the pager/floor work that comes with it.

Another issue is that the more residents the program takes on, the more GME funding they get, so a lot of program directors are under pressure to take on additional residents just for that reason. Just another example of how what's good for podiatry is often bad for podiatrists.

Very aware of the push to hire more residents based on increased compensation. Without doxing myself, our program director was constantly trying to add another resident but we as a resident group said no because it would dilute the volume. So we fluffed our hours knowing some call weeks sucked (and there were plenty of call weeks early on) but you got more cases the other weeks.

 

[Feli]

Very aware of the push to hire more residents based on increased compensation. Without doxing myself, our program director was constantly trying to add another resident but we as a resident group said no because it would dilute the volume. So we fluffed our hours knowing some call weeks sucked (and there were plenty of call weeks early on) but you got more cases the other weeks.

There is also pressure on the other side (APMA, who approves too many schools/seats, wants more residency spots).

My program was 4/yr and told they could take 8/yr as "there are plenty of surgical cases" and should add spots asap. A podiatry residency shortage was looming when AZPod and then Western Pod opened. Luckily, director shot that down (stayed at 4/yr), but many other programs took the bait ($$$) and watered down the training. A residency shortage still occurred a few years later with more pod grads than spots (FAR more grads than good spots).

 

[diabeticfootdr]

-Yes you can. If resident A and B both log it as a first assist it doesn’t get caught. They can log the same code, day and patient.

-It happens and is sad.

Why I think audits are important…

You can add anything you want to the log, but the residency director has to verify it in PRR before it is accepted. There is an error alert when 2 residents log the same level of participation on the same patient on same date of service.

That is the first level of audits.

The second level of audit are CPME spot checks on the logs (done remotely) prior to resident graduation.

The third level of audit is during a site visit when logs are scrutinized by the CPME site evaluators.

What other audit do you think will be helpful?

 

[diabeticfootdr]

Is there any oversight or way to look at a programs volume of surgical cases versus number of residents and say you only qualify for x number of spots based on your production. I get there's a minimum requirement of cases and diversity in cases which should kind of dictate that but the minimum requirement is laughably low. It would decrease the number of resident slots, absolutely, but would lead to better training and decrease some of this first/second assist nonsense with multiple residents scrubbing cases.

It's done during the CPME review for continuing approval and by site evaluators.

But if there are enough surgical (and other experience) numbers to support an increase in the resident complement, it's up to the program leadership to decide on a complement increase. But they must apply to CPME for that.

I don't agree with the minimum activity volumes because they don't take into account the individual differences in learning. One resident may demonstrate competence after 5 similar procedures and another may need 20. That's why the ACGME Milestone Model is a better assessment tool and should be used by CPME.

 

[Homo sapien]

You can add anything you want to the log, but the residency director has to verify it in PRR before it is accepted. There is an error alert when 2 residents log the same level of participation on the same patient on same date of service.

That is the first level of audits.

The second level of audit are CPME spot checks on the logs (done remotely) prior to resident graduation.

The third level of audit is during a site visit when logs are scrutinized by the CPME site evaluators.

What other audit do you think will be helpful?

The point we are making is that the logs don't always reflect reality. A resident may log 85 first rays, but only physically did 15 of them. So 15/85 is the true experience. But there's a false idea of skill because a director approved all 85

 

[Sendin_Toes_2market]

The point we are making is that the logs don't always reflect reality. A resident may log 85 first rays, but only physically did 15 of them. So 15/85 is the true experience. But there's a false idea of skill because a director approved all 85

.

 

[shadesofgrey]

Agree with the variance and not being able to trust the numbers. I had a coresident, who was not interested in surgery, he would literally slowly back away from the OR table. The attending would either inevitably keep the knife or if a junior resident was scrubbed in would have the junior resident perform the surgery. He is a non-op mainly, nail care, doc now. However, he got his numbers/took numbers from other residents. Residency for him was really a waste. He had no desire for surgery but needed residency to practice in his desired state.

I'm not sure there is a perfect solution to document/show proficiency. The numbers method fails because residents are only trying to score numbers of surgeries. The other method is dependent on the attending being honest about how proficient, in his opinion, the resident is.

 

[Dermato Fight Club]

Maybe you misunderstand the standards. Here is the standard for resident activity during surgeries from CPME 320:
View attachment 406350

So you might disagree with the language of the standard, but they are meeting the standard.

I have not kept up with this. Did this change? I graduated residency in 2012. I believe we used the A/B/C method where basically A was you did over 50% of the case and B was you did less than 50% of the case and C was like you were first assistant. We didn't even log C's (first assistant).

Now we are allowing first assistants to log cases as if they actually performed the procedure?

So we not only diluted our training by adding more residents to residency programs, but we've lowered the standards to what should have already been an easy bare minimum threshold to achieve.

 

[MicroPod]

Hate to say it but my program had some attendings who didn’t let residents do much other than maybe open and close. Of course you were in charge of dictating, putting in orders and the like though. And yes we still logged these cases. Had plenty of attendings so never had to double scrub at least. In my final residency interview I told our program director we shouldn’t be working with attendings that don’t let residents do anything, doubt things will change.

 

[Adam Smasher]

I hate to say it but if I has at a hospital with a residency program, I probably wouldn't let the resident do much either. And here's the rub. If you're a small-time attending who schedules < 10 elective cases per month, you might not have the same resident scrubbing with you on any given OR day. You might be meeting this person for the first time, no clue about their competence, do you just hand them the blade like that? And you don't necessarily have time to teach this person because you have to get through your cases so you can see office patients scheduled at 1pm. So this is the difference between a residency having case volume and volume of actual teaching cases.

 

[MicroPod]

I hate to say it but if I has at a hospital with a residency program, I probably wouldn't let the resident do much either. And here's the rub. If you're a small-time attending who schedules < 10 elective cases per month, you might not have the same resident scrubbing with you on any given OR day. You might be meeting this person for the first time, no clue about their competence, do you just hand them the blade like that? And you don't necessarily have time to teach this person because you have to get through your cases so you can see office patients scheduled at 1pm. So this is the difference between a residency having case volume and volume of actual teaching cases.

Yeah we would only be with attending for 1-2 months at a time so they didn’t get to know us well. My final year we were assigned to certain attendings for longer so it was way better plus they kinda trusted us since we were 3rd year.

 

[Feli]

I hate to say it but if I has at a hospital with a residency program, I probably wouldn't let the resident do much either. ....

You just have to pimp them a bunch at the start (tourniquet, local, gown, prep/drape) to see how much you should expect/allow of them.

I've worked with VG/excellent programs and fair/poor ones, and they all get solid and dud residents (both knowledge and hand skills).

Most of the highest competency attendings are the most hands-off in my exp (unless it's a real big case or important pt... or they are just in a hurry for whatever reason). There are some who are good but nearly always rushed for the case, to get back to office, whatever. That is lame, but still good watch + learn.

 

[Boba Foot]

I hate to say it but if I has at a hospital with a residency program, I probably wouldn't let the resident do much either. And here's the rub. If you're a small-time attending who schedules < 10 elective cases per month, you might not have the same resident scrubbing with you on any given OR day. You might be meeting this person for the first time, no clue about their competence, do you just hand them the blade like that? And you don't necessarily have time to teach this person because you have to get through your cases so you can see office patients scheduled at 1pm. So this is the difference between a residency having case volume and volume of actual teaching cases.

Just finished (hopefully) dealing with a complication from a resident not doing a procedure correctly. I've been pretty generous in letting residents do things, but I think I'm about to change my policy on that. They don't have to deal with the complications from them not preparing properly; I do.

 

[Homo sapien]

Just finished (hopefully) dealing with a complication from a resident not doing a procedure correctly. I've been pretty generous in letting residents do things, but I think I'm about to change my policy on that. They don't have to deal with the complications from them not preparing properly; I do.

Do you have to work with residents?