The very simple solution to combating residency expansion

[thesauce]

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I will post this once again because it seems to have been missed

There is a very simple solution to the residency expansion issue. It doesn't require a ton of advocacy and you don't have to convince a committee or even any chairmen. Ironically, it involves doing LESS WORK than we are already doing.

RESIDENTS: PLEASE LOG NO MORE THAN THE MINIMUM 450 CASES!

The committees that approves expansions must justify this based on volume and they look at resident case logs to prove there are enough cases. I know of a number of programs that have been turned down because there was insufficient evidence to support an increase in the number of residents.

From going through the job hunt recently, I can tell you that no one cares if you have 450 or 1,000 cases logged. No one asked me how many cases I did and I was certainly never asked to produce my case logs.

 

[Chartreuse Wombat]

I will post this once again because it seems to have been missed

There is a very simple solution to the residency expansion issue. It doesn't require a ton of advocacy and you don't have to convince a committee or even any chairmen. Ironically, it involves doing LESS WORK than we are already doing.

RESIDENTS: PLEASE LOG NO MORE THAN THE MINIMUM 450 CASES!

The committees that approves expansions must justify this based on volume and they look at resident case logs to prove there are enough cases. I know of a number of programs that have been turned down because there was insufficient evidence to support an increase in the number of residents.

From going through the job hunt recently, I can tell you that no one cares if you have 450 or 1,000 cases logged. No one asked me how many cases I did and I was certainly never asked to produce my case logs.

Setting aside the ethical implications- residents and program directors are expected to keep up to date and accurate logs according to the ACGME requirements- in my experience as a PD for more than 20 years for the purposes of credentialling hospitals are increasingly asking for the specifics of cases, especially brachytherapy, SBRT and SRS. Of course one could just lie about that as well.
Ironically I share your concern about workforce issues. Despite calls from my faculty and the residents I have not increased the resident complement; instead meeting increased clinical needs with physician extenders and the like.
I believe that the medical students are getting the message. In my unscientific survey the number of interested residents from the several schools that I track has been steadily decreasing. HMS had 13 last year and only 4-5 this year, one case of course but I believe that the message is being communicated.

 

[radiaterMike]

Something else to consider. 450 is the minimum and probably ok for Holman pathway candidates. The residency review committee will want programs to have residents log more cases. While that may be the point you are making, if all of the residents are reporting low numbers, the response from your program may be to (justifiably) increase case numbers by combining services and/or restricting elective time.


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[thesauce]

Setting aside the ethical implications- residents and program directors are expected to keep up to date and accurate logs according to the ACGME requirements- in my experience as a PD for more than 20 years for the purposes of credentialling hospitals are increasingly asking for the specifics of cases, especially brachytherapy, SBRT and SRS. Of course one could just lie about that as well.
Ironically I share your concern about workforce issues. Despite calls from my faculty and the residents I have not increased the resident complement; instead meeting increased clinical needs with physician extenders and the like.
I believe that the medical students are getting the message. In my unscientific survey the number of interested residents from the several schools that I track has been steadily decreasing. HMS had 13 last year and only 4-5 this year, one case of course but I believe that the message is being communicated.

I appreciate your concern for our workforce issues and let me say thanks for being one of the good PDs that has looked beyond their personal interests.

To address your comments:
Ethical implications? I seriously hope you're joking. The demand for (actually want of) cheap labor in the academic market is what triggered this unnecessary growth in the first place. Academic departments keep their departments solvent by leveraging the futures of their hard-working residents and we're suppose to feel bad for not logging some sims?

If you truly believe resident case logs are accurate now, I've got some bad news for you. I have rotated through 7 academic departments and no two log their cases the same way (either in format or what they "count"). And unfortunately, the logs are more often inflated on the upper end so trainees can brag about having a thousand sims in hopes some future employer will care (they won't). Then there are 2 programs that I know very well that have, for years, logged 450 and stopped. These programs applied for expansion and were denied because of insufficient cases.

While you are correct that some hospitals may ask for case logs, I have never heard of anyone being denied privileges or even having limitations as a result of an inadequate number of cases. Have you? Brachytherapy, SRS, and SBRT may be scrutinized, but not standard EBRT, which is what the vast majority of the case logs reflect. No one cares if you have 200 or 700 EBRT cases.

 

[thesauce]

Something else to consider. 450 is the minimum and probably ok for Holman pathway candidates. The residency review committee will want programs to have residents log more cases. While that may be the point you are making

Yes, that is exactly my point

if all of the residents are reporting low numbers, the response from your program may be to (justifiably) increase case numbers by combining services and/or restricting elective time.

Do you seriously think that's such a bad trade-off? Better that than to have to do a fellowship because you can't find a job.

 

[radiaterMike]

Yes, that is exactly my point



Do you seriously think that's such a bad trade-off? Better that than to have to do a fellowship because you can't find a job.

Yes I think sabotaging your own residency experience is a bad trade off because it may or may or not help with the issue and certainly won't help in the short term (meaning years) but realistically can make your life miserable during residency. The solution is to enlist ARRO, ACRO, ASTRO and the board the accredits and potentially expands programs to address work force issues. From what I can tell the message is being heard by some who have influence. Perhaps ARRO leadership (who are elected officials and can certainly 'campaign' on this issue) needs to take a bigger role in making some noise.


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[Chartreuse Wombat]

I appreciate your concern for our workforce issues and let me say thanks for being one of the good PDs that has looked beyond their personal interests.

To address your comments:
Ethical implications? I seriously hope you're joking. The demand for (actually want of) cheap labor in the academic market is what triggered this unnecessary growth in the first place. Academic departments keep their departments solvent by leveraging the futures of their hard-working residents and we're suppose to feel bad for not logging some sims?

If you truly believe resident case logs are accurate now, I've got some bad news for you. I have rotated through 7 academic departments and no two log their cases the same way (either in format or what they "count"). And unfortunately, the logs are more often inflated on the upper end so trainees can brag about having a thousand sims in hopes some future employer will care (they won't). Then there are 2 programs that I know very well that have, for years, logged 450 and stopped. These programs applied for expansion and were denied because of insufficient cases.

While you are correct that some hospitals may ask for case logs, I have never heard of anyone being denied privileges or even having limitations as a result of an inadequate number of cases. Have you? Brachytherapy, SRS, and SBRT may be scrutinized, but not standard EBRT, which is what the vast majority of the case logs reflect. No one cares if you have 200 or 700 EBRT cases.

With respect-you are conflating two different things.
It is one thing if some of the logs are not 100% correct; no one expects perfection. Aadditionally, the program requirements as written do allow room for interpretation of how to count cases; the ACGME acknowledges this.
It is another thing to recommend that residents intentionally misrepresent their experiences for the purposes of another goal.
You may operate with an ends justifies the means approach; increasingly this is viewed as acceptable.
I cannot abide. In my view intentional misrepresentation is not something that anyone should condone or advocate.

To your question about number of cases. I agree with you about standard external beam cases but hospitals are recognizing that procedures (while lucrative) can be a source of risk. There a number of well publicized mistakes/errors with brachytherapy, SBRT and SRS. In fact, I am aware of two residents with <10 prostate brachytherapy cases were not granted approval to perform prostate brachytherapy unless proctored by an authorized user for the first 5 cases. In each case this request was easily met by one of their colleagues helping out. Were they denied privileges? Not exactly.
My point is that in the last five years I have been asked to verify resident case logs by many credentialling hospitals; a practice that I had not observed previously (consistent with your own impression).

 

[medgator]

Yes I think sabotaging your own residency experience is a bad trade off because it may or may or not help with the issue and certainly won't help in the short term (meaning years) but realistically can make your life miserable during residency. The solution is to enlist ARRO, ACRO, ASTRO and the board the accredits and potentially expands programs to address work force issues. From what I can tell the message is being heard by some who have influence. Perhaps ARRO leadership (who are elected officials and can certainly 'campaign' on this issue) needs to take a bigger role in making some noise.


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Except those solutions will take years to work out (if at all) while residents can help the problem now. And it is a problem NOW if the most recent published data and anecdotal experience from many of us is to be believed

 

[thesauce]

Yes I think sabotaging your own residency experience is a bad trade off because it may or may or not help with the issue and certainly won't help in the short term (meaning years) but realistically can make your life miserable during residency. The solution is to enlist ARRO, ACRO, ASTRO and the board the accredits and potentially expands programs to address work force issues. From what I can tell the message is being heard by some who have influence. Perhaps ARRO leadership (who are elected officials and can certainly 'campaign' on this issue) needs to take a bigger role in making some noise.

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First off, "sabotaging your own residency" and making "your life miserable during residency" are gross exaggerations. There are already plenty of programs out there with limited elective time which produce excellent and happy physicians. But even if true, I would be extremely surprised if the vast majority of residents would not trade a more miserable few years of residency (which are already supposed to be miserable - mine sure was) in exchange for better options in the job market when they get out. I honestly can't think of a single resident that wouldn't make that trade except you.

Ultimately, I see this exactly the opposite. You say that logging 450 may not help the problem, but will definitely force changes in the curriculum. I believe that logging 450 GUARANTEES the problem is solved because programs cannot justify expansion without the numbers and it PROBABLY WON'T force changes in the curriculum (at least not quickly and probably not at all) for most programs since PDs still want to keep their program desirable for applicants.

Enlisting the help of ARRO, ACRO, ASTRO and the boards the accredit and expand programs is clearly not the solution as these institutions are either not allowed to take work-force issues into consideration or are altogether powerless on the matter. Plus, we've been trying this.

 

[radiaterMike]

Except those solutions will take years to work out (if at all) while residents can help the problem now. And it is a problem NOW if the most recent punished data and anecdotal experience from many of us is to be believed

The only changes "now" will be program directors who say "hmmm your case loads are really low, you'll have to skip your pathology elective and pick up more cases and we'll need to think about combining services so the case loads aren't so low". Meanwhile if they submitted for expansion, they'll be submitting recent years' case logs. If you want changes now you need to get those who have some influence to halt expansion and consider reductions in some programs. If SCAROP and ASTRO are dragging their feet use YOUR elected officials (ARRO) as a voice and make sure that when ARRO elections come around you actually read their self-promoting blurb and elect those who have a concrete plan to address this. As CW has said intentional fraudulent reporting to the ACGME will not end well for you and will be unlikely to result in any meaningful change.


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[radiaterMike]

First off, "sabotaging your own residency" and making "your life miserable during residency" are gross exaggerations. There are already plenty of programs out there with limited elective time which produce excellent and happy physicians. But even if true, I would be extremely surprised if the vast majority of residents would not trade a more miserable few years of residency (which are already supposed to be miserable - mine sure was) in exchange for better options in the job market when they get out. I honestly can't think of a single resident that wouldn't make that trade except you.

Ultimately, I see this exactly the opposite. You say that logging 450 may not help the problem, but will definitely force changes in the curriculum. I believe that logging 450 GUARANTEES the problem is solved because programs cannot justify expansion without the numbers and it PROBABLY WON'T force changes in the curriculum (at least not quickly and probably not at all) for most programs since PDs still want to keep their program desirable for applicants.

Enlisting the help of ARRO, ACRO, ASTRO and the boards the accredit and expand programs is clearly not the solution as these institutions are either not allowed to take work-force issues into consideration or are altogether powerless on the matter. Plus, we've been trying this.

It's amusing to me that the stronger proponents of this have been in practice for years and won't have to face the repercussions of fraudulent reporting.


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[medicinewoman101]

It's amusing to me that the stronger proponents of this have been in practice for years and won't have to face the repercussions of fraudulent reporting.

Suit yourself but this is a quite rationale option.

I remember speaking with a friend who was in residency in the south and at her program they would not let any sims get left behind bc residents were told to log every case that was done in the department so that they could justify getting more residents. At the time we thought "how cool, you're going to get exposure to so many cases". She ended up double covering attendings and tripling up bc of the prostate sims that were not to be left behind and having to contour those cases and get called out of consults to set a f*cking iso. It's abundantly clear what was going on. The low-life attendings that perpetuated that should be ostracized here, they know who they are.

 

[thesauce]

With respect-you are conflating two different things.
It is one thing if some of the logs are not 100% correct; no one expects perfection. Aadditionally, the program requirements as written do allow room for interpretation of how to count cases; the ACGME acknowledges this.
It is another thing to recommend that residents intentionally misrepresent their experiences for the purposes of another goal.
You may operate with an ends justifies the means approach; increasingly this is viewed as acceptable.
I cannot abide. In my view intentional misrepresentation is not something that anyone should condone or advocate.

I'll bet I can guess where you stand on logging duty hours.

Can you please show me the policy that states that residents must log every sim? I don't see that verbiage in the requirements: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/430_radiation_oncology_2016.pdf

It says that logs must be detailed and accurate with regard to the "at least" 450 cases (and other procedural minimums). I don't see where it says every case needs to be counted, but please direct me. There is also a policy of no more than 250 external beam cases per year, but I know PDs who have asked their residents to take off some cases so they can fall below that mark.

To your question about number of cases. I agree with you about standard external beam cases but hospitals are recognizing that procedures (while lucrative) can be a source of risk. There a number of well publicized mistakes/errors with brachytherapy, SBRT and SRS. In fact, I am aware of two residents with <10 prostate brachytherapy cases were not granted approval to perform prostate brachytherapy unless proctored by an authorized user for the first 5 cases. In each case this request was easily met by one of their colleagues helping out. Were they denied privileges? Not exactly.

Not exactly and not at all. If you aren't board certified, many hospitals require you must be proctored in the first several cases regardless of your experience. This depends on the state (in an agreement state) and that hospital's individual policies. Maybe that's a new thing, but doesn't greatly impact whether 200 or 700 EBRT cases need to be logged. In the example given: if you were trying to make the point that these residents were somehow hurt by having logged fewer than 10 prostate brachy cases, you've shown the exact opposite: "the request was easily met."

 

[Chartreuse Wombat]

I'll bet I can guess where you stand on logging duty hours.

Can you please show me the policy that states that residents must log every sim? I don't see that verbiage in the requirements: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/430_radiation_oncology_2016.pdf



It says that logs must be detailed and accurate with regard to the "at least" 450 cases (and other procedural minimums). I don't see where it says every case needs to be counted, but please direct me. There is also a policy of no more than 250 external beam cases per year, but I know PDs who have asked their residents to take off some cases so they can fall below that mark.



Not exactly and not at all. If you aren't board certified, many hospitals require you must be proctored in the first several cases regardless of your experience. This depends on the state (in an agreement state) and that hospital's individual policies. Maybe that's a new thing, but doesn't greatly impact whether 200 or 700 EBRT cases need to be logged. In the example given: if you were trying to make the point that these residents were somehow hurt by having logged fewer than 10 prostate brachy cases, you've shown the exact opposite: "the request was easily met."[/QUOTE

Really? I guess your definition of accurate is different than mine. I can only hope that medical students and residents understand what accurate means and I would ask them not to engage in this subterfuge..

I will sign off now as this is unproductive and unlikely to change your mind.

 

[DebtRising]

You also need to start being honest with every single medical student who rolls through the department. No hype, no glamour, no personal opinion. This is what I show them now. So far no blow back from attendings.

1. ~7% unemployment rate for graduates in 2014. 30%+ couldn't find a job in their geographic region.
http://www.redjournal.org/article/S0360-3016(15)00337-5/abstract
You want to argue the terminology? Read the definition of unemployment by the BLS.
2. Rabid, non-accredited fellowship expansion that frequently offer nothing that should not be part of a standard residency
I started to pass out the ARRO list and show them the MSKCC lymphoma one (conveniently the first google result). I had one student, who was doing a lymphoma rotation, actually stare at me in disbelief.
3. New, specialty specific labor market study that projects that "supply of radiation oncologists predicts to outpace demand' from 2015- 2025
http://www.ncbi.nlm.nih.gov/pubmed/27209499
4. The latest editorial on the job market
http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

And I do this with the full disclosure that no one has the ability to predict the future and 0 of the passion I display at times here. But it's really hard to argue with objective data. And quite frankly they have a right to know - if you are entering a paid internship of 5 years, during which you may accumulate enough additional debt as to wipe out ~30-50% of your earnings depending on your situation, it is absurd that there is such little data about actual job prospects. And that may be the most salient point - no one in a position to really monitor or evaluate this deeper even cares enough to discuss this with potential applicants.

 

[medicinewoman101]

You also need to start being honest with every single medical student who rolls through the department. No hype, no glamour, no personal opinion. This is what I show them now. So far no blow back from attendings.

1. ~7% unemployment rate for graduates in 2014. 30%+ couldn't find a job in their geographic region.
http://www.redjournal.org/article/S0360-3016(15)00337-5/abstract
You want to argue the terminology? Read the definition of unemployment by the BLS.
2. Rabid, non-accredited fellowship expansion that frequently offer nothing that should not be part of a standard residency
I started to pass out the ARRO list and show them the MSKCC lymphoma one (conveniently the first google result). I had one student, who was doing a lymphoma rotation, actually stare at me in disbelief.
3. New, specialty specific labor market study that projects that "supply of radiation oncologists predicts to outpace demand' from 2015- 2025
http://www.ncbi.nlm.nih.gov/pubmed/27209499
4. The latest editorial on the job market
http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

And I do this with the full disclosure that no one has the ability to predict the future and 0 of the passion I display at times here. But it's really hard to argue with objective data. And quite frankly they have a right to know - if you are entering a paid internship of 5 years, during which you may accumulate enough additional debt as to wipe out ~30-50% of your earnings depending on your situation, it is absurd that there is such little data about actual job prospects. And that may be the most salient point - no one in a position to really monitor or evaluate this deeper even cares enough to discuss this with potential applicants.

The applicant stage is often too late. I do agree that this information needs to be available and our audience here is quite large. It is clear that the experiences we have had in our academic program in the last 3-4 years is a shared one. These so called leaders are exploiting the system for their own benefit which has the potential to lead to widespread disaster in our field, partly this has already happened. This has been christened by chairs who for some reason we still look up to. It happens in other fields too obviously, but we finally have a group of people wiling to speak out about it instead of suppress the dissenters like we had 3-4 years ago. Radiologists and pathologists did not speak out, look what happened to them. Theres is a system that so totally and completely failed those kids.

Meds students need to read our experiences. And if your friend is thinking "hey I want to be a radiation oncologist, it sounds so cool" please point them toward our message board so they can understand what lies ahead. They might still choose to do it, but as you can tell many of us, not just 1 of us, would not recommend it. And if you are a transitional/prelim intern its not too late to consider other options.

 

[Krukenberg]

You also need to start being honest with every single medical student who rolls through the department. No hype, no glamour, no personal opinion. This is what I show them now. So far no blow back from attendings.

1. ~7% unemployment rate for graduates in 2014. 30%+ couldn't find a job in their geographic region.
http://www.redjournal.org/article/S0360-3016(15)00337-5/abstract
You want to argue the terminology? Read the definition of unemployment by the BLS.
2. Rabid, non-accredited fellowship expansion that frequently offer nothing that should not be part of a standard residency
I started to pass out the ARRO list and show them the MSKCC lymphoma one (conveniently the first google result). I had one student, who was doing a lymphoma rotation, actually stare at me in disbelief.
3. New, specialty specific labor market study that projects that "supply of radiation oncologists predicts to outpace demand' from 2015- 2025
http://www.ncbi.nlm.nih.gov/pubmed/27209499
4. The latest editorial on the job market
http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

And I do this with the full disclosure that no one has the ability to predict the future and 0 of the passion I display at times here. But it's really hard to argue with objective data. And quite frankly they have a right to know - if you are entering a paid internship of 5 years, during which you may accumulate enough additional debt as to wipe out ~30-50% of your earnings depending on your situation, it is absurd that there is such little data about actual job prospects. And that may be the most salient point - no one in a position to really monitor or evaluate this deeper even cares enough to discuss this with potential applicants.

This would only reduce residency expansion if departments responded to a drop in medical student quality with stopping their expansions and maybe even contracting the resident pool. I think that if you reduce the number of AMGs applying to rad onc there will still be enough IMGs to fill spots. The departments most likely to expand are probably also least likely to go unfilled in the match.


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[DebtRising]

No, it may not, but information is powerful and it is very hard to argue with objective data. If we continue to show how bad the job market is, and how programs are only seemingly trying to capitalize on this by offering more fellowships, and doing it openly and honestly, I think that would have a huge impact. At this time how many people apply without rotating through at least 2 departments?

Also - if the field is suddenly influxed with IMGs and there are higher unfilled slots, then that gives an objective data point to both ACGME (which seems to be a very odd 1-way body....) and better yet to Medicare, and provides a rational argument for dropping specialty specific medicare funding of slots (ie - why are you training so many graduates with tax payer money if your own field's labor projection suggests over supply and you can't fill the slots you have now with American graduates?). Won't hurt programs that self fund - but that is a much bigger commitment than someone else's dime.

 

[Gfunk6]

Although I applaud the OP for trying to do something substantial to prevent unbridled residency expansion, I'm afraid that I must admit this plan comes off as sounding naïve. I think there are several problems:

1. The fundamental asymmetry between residents and faculty. Unlike the regular relationship between an employee-employer, the resident-faculty relationship is akin to indentured servitude. If a true employee feels that (s)he is being mistreated, underpaid or is simply dissatisfied with the job, (s)he can walk away, find a new position, and continue - usually with minimal repercussions. In the case of residents, your program director (if vindictive or petty) can actually see to it that you never practice Rad Onc and (even further) can render your MD training essentially worthless. This asymmetry of power is what is driving the culture of subservience in residency program. If the PD asks you to jump, you ask how high.

2. ACGME logs are used for multiple purposes, not just residency expansion. People need to ensure that residents are not being overwhelmed - we can all agree that if you go >>450 cases then there is a point of diminishing returns in educational value. In those scenarios, options include (groan) more residents or at least having attendings see their own patients. Also, it is important for some jobs to log special procedures. In my case, I was BE when I completed residency. To be eligible for my name to be on our practice radioactive materials license, I had to provide a log of all of the HDR brachy cases that I did.

3. PDs are not stupid. They will notice residents are underlogging and ask them to stop, see point #1.

4. Residents, having gone through the trial by fire that is the medical education system are naturally competitive. It is actually a point of pride for some programs that work the residents to the bone (MSKCC) that they come out of the crucible ready and able to do just about anything.

In an ideal world, there would be some grand committee who oversees residency slots and the job market and would used a nuanced and thoughtful approach in expansion. However, in our situation, the market will dictate it. Sadly, this has the unhappy side effect of hurting a lot of people (mostly the ones in training) but eventually when people realize that jobs are tight and desirable location is a nonfactor then the resident pool will contract. The field will reach a sorry state (see pathology) but that's the way it works.

 

[McConaughey]

A simulation should only be counted if the resident participated in all aspects and received teaching and feedback. That puts it back on the faculty to do their job (teach) and if truly implemented would reduce bloated numbers a resident may have counted but was just peripherally involved in.


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[deleted18755]

Does anybody know what the requirements actually are? Big difference for a nasopharyngeal cancer (or anything other than WBRT or simple bone mets) between being at sim to ensure proper reproducible set up and immobilization, isocenter placement, then contouring everything, sitting down with attending to review slice by slice, submitting volumes to dosimetrist, then analyzing and discussing the plan a few days later and running in to place isocenter, filling out all paperwork for attending, then running out and counting that as a "sim" or "case."

 

[thesauce]

Gfunk: I appreciate your input.

I don't disagree with anything you've said, but I think you and I are looking at this a bit differently. I think you see this as an "us versus them" issue and you perceive the intent/outcome behind this approach is to start a conflict between the resident and the PD. I agree that's a very bad idea, but I don't see that being a common outcome.

I can't speak for everyone's PD, but mine never mentioned case logs even once in all 4 years of residency and everyone in my program stopped logging at 450. And everyone in my PDs program also stopped logging at 450. She simply looked at it as: you got 450? Great...check.

If someone has a PD that they believe will be angered by this (such as CW obviously is) then by all means don't do it. But my PD can't be the only one that is pretty passive re: case logs and if yours is one, I don't see a downside. This is a form of passive protest that can have a real and immediate impact in correcting the problem.

As for the case logs being needed for privileges, we did discuss brachy, SRS, and SBRT being in a different category. I wouldn't skimp on counting those, but counting your 150th whole brain or bone met sim is absolutely worthless.

 

[ToasterThief]

From a recent posting: "Upon completion of the fellowship, the individual should be well prepared to launch a career in an academic setting or community practice."

Anyone else find this as insulting as I do?

 

[thesauce]

From a recent posting: "Upon completion of the fellowship, the individual should be well prepared to launch a career in an academic setting or community practice."

Anyone else find this as insulting as I do?

Yep.

It should read "BEFORE completion of the fellowship, the individual should be well prepared to launch a career in an academic setting or community practice."

They are suggesting this is the goal of the fellowship, which of course questions the quality of the participant's residency training.

 

[DukeNukem]

I can't speak for everyone's PD, but mine never mentioned case logs even once in all 4 years of residency and everyone in my program stopped logging at 450. And everyone in my PDs program also stopped logging at 450. She simply looked at it as: you got 450? Great...check.

Your program probably didn't want to expand. My former residency program has been expanding rapidly for a few years now, and the chair, PD, and most of the faculty wish to continue to expand both the residency and fellowship programs to provide more attending coverage.

At our 6 month meetings, the PD always scrutinized our cases and they wanted to make sure that we were well over 450 cases when we graduated. Anyone who wasn't on track to be well over 600 would be interrogated as to their case logs, and some residents lost research time over it. Nobody would dare to not log their cases. If you were caught not logging cases, I imagine that you would end up in big trouble. Certainly my residency colleagues felt that way, and they also felt that your idea would not work at our program.

 

[thesauce]

Your program probably didn't want to expand. My former residency program has been expanding rapidly for a few years now, and the chair, PD, and most of the faculty wish to continue to expand both the residency and fellowship programs to provide more attending coverage.

At our 6 month meetings, the PD always scrutinized our cases and they wanted to make sure that we were well over 450 cases when we graduated. Anyone who wasn't on track to be well over 600 would be interrogated as to their case logs, and some residents lost research time over it. Nobody would dare to not log their cases. If you were caught not logging cases, I imagine that you would end up in big trouble. Certainly my residency colleagues felt that way, and they also felt that your idea would not work at our program.

As I said, it won't work for all programs, but if even a few do it, it will have an impact.

Also, if your PD wants "well over" 600, don't log a thousand just to try and look like a badass, log 650. Keeps everyone happy. If residents even cut down, it will have an impact.

Our residency did request an expansion, BTW. I mentioned that above. They were denied because of not having sufficient cases. Our PD was like "oh well." Guess we need to start logging more in the future and then just never followed through. I think she finally decided it wasn't needed that badly once she saw the decreased demand of RT in early stage prostate and lymphoma.

 

[deleted18755]

From a recent posting: "Upon completion of the fellowship, the individual should be well prepared to launch a career in an academic setting or community practice."

Anyone else find this as insulting as I do?

This is actually why I would consider completion of a fellowship to be a big red flag when evaluating a job candidate. I would assume that the applicant left residency completely unprepared and question why he completed a fellowship. Of course I would be understanding if he said something like "I experienced a horrible personal/family tragedy and wasn't able give it my all" or "my program collapsed/went through significant changes while I was there and this greatly affected my training so I felt as though I needed remediation or an extra year to become competant" or "my wife had one more year of training before we moved our family cross country and this was the only position I could find within a 40-50 mile radius."

If somebody acted proud that they are Harvard, Stanford, MD Anderson "fellowship training" I would consider them a fool and somebody who is very poor at making major life decisions (and I'm sure somebody with more malicious hiring practices would consider him a fool who would be easy to hire, take advantage of, then fire.

 

[DebtRising]

Your program probably didn't want to expand. My former residency program has been expanding rapidly for a few years now, and the chair, PD, and most of the faculty wish to continue to expand both the residency and fellowship programs to provide more attending coverage.

At our 6 month meetings, the PD always scrutinized our cases and they wanted to make sure that we were well over 450 cases when we graduated. Anyone who wasn't on track to be well over 600 would be interrogated as to their case logs, and some residents lost research time over it. Nobody would dare to not log their cases. If you were caught not logging cases, I imagine that you would end up in big trouble. Certainly my residency colleagues felt that way, and they also felt that your idea would not work at our program.

How many of those cases were sims you did the paperwork on... and how many of them had meaningful attending input - the setup was reviewed, the volumes were reviewed and discussed, the plan was reviewed together.

This is the data we need. In surgery, the resident has to physically be present at a case to log it. And the resident cannot be at the case alone, so an attending must be there as well. In our field, we can be scutted out to sign the documents for a WBRT sim we essentially never touch, can have the plan signed off while we are seeing new patients, and still be pressured into logging it as a 'case'. This data is then used to justify program expansion, and at times taxpayer money for training slots.

We need to get the data on the level of academic interest an mentoring in these increased case logs, because I suspect most of these logs are actually fraudulent - ie sure, you 'performed' the sim by being present and signing a document, but you didn't set the fields because 'its a routine case' and it got approved while you were seeing a consult because 'it was straight forward... we can go over it later'.

Maybe ACGME logging for our field needs to be by both attending and resident - then if discrepancies arise in case ID and dates its a red flag that really wasn't an educational case. The attending should also specify what level the resident was able to function at - ie were the volumes drawn correctly, did the resident have understanding of the prescription review process and critical doses. We should push at ARRO to make this change immediately. The argument that its more work for an attending is false - I already saved you time by doing all the paperwork for the sim and most likely by doing volumes that saved you either minutes or hours depending on the case and complexity (as well as the consult note you didn't write). It almost certainly would improve educational standards and thus patient care for the whole field, and if this expansion is driven by the love of education then this improved reporting is a no-brainer. It is also an easy sell to ACGME and Medicare funding bodies and would help patients.

 

[Krukenberg]

Maybe ACGME logging for our field needs to be by both attending and resident - then if discrepancies arise in case ID and dates its a red flag that really wasn't an educational case. The attending should also specify what level the resident was able to function at - ie were the volumes drawn correctly, did the resident have understanding of the prescription review process and critical doses. We should push at ARRO to make this change immediately. The argument that its more work for an attending is false - I already saved you time by doing all the paperwork for the sim and most likely by doing volumes that saved you either minutes or hours depending on the case and complexity (as well as the consult note you didn't write). It almost certainly would improve educational standards and thus patient care for the whole field, and if this expansion is driven by the love of education then this improved reporting is a no-brainer. It is also an easy sell to ACGME and Medicare funding bodies and would help patients.

Or we as residents could only log sims that had educational value. If a PD brings up lower than average case numbers it's completely legitimate to say that there are sims where all you did was fill paperwork and you didn't feel it was log-worthy.


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