Hospital Administration threatening to make cuts to program

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Phil Dunphy

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Hospitals receive funding for residents, but they still put in some of their own money. Some hospitals also self-fund additional residents beyond what the government will fund. I doubt you have any recourse as you are a captive, vulnerable population.

Resident coverage of the ICU on weekends is pretty common, though even in our University hospital every ICU chooses to staff differently. Some have at least two residents at all times with NP and resident coverage during the day, which then sign out to the long call or night residents. Another has a single 24 hour shift for an NP with several day residents and a single night resident with that NP only picking up patients beyond the unit's resident cap, another has 24 hour NP shifts with no overnight resident and decreased weekend resident coverage, while another has multiple day NPs with a resident team, then one resident overnight with an NP, fellow, or both.
 
Phil Dunphy said:
a main reason we were given the number of residents that we have (we recently increased the size of our program by about 50% two years ago) was in order to increase resident staffing of the ICU.
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The extra residents started 2 years ago, so they apparently knew about this change 2 years ago. Why are they telling you this now? I understand they want you to do this, and you're likely going to have to do it, but either they're terrible about sharing their plans with you, or (more likely) they're just lying to you.
 
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Sounds like a substantial decrease in quality of life for the interns/residents. You should have all the residents/interns take a burnout inventory questionnaire now and then later if these changes do come to be.
 
Sounds like you had a pretty cush residency program. My Pre-lim year had all residents doing full blown MICU rotations, weekends, 24 hr call, etc. Just be glad you're a chief and not an intern.
 
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I dont think midlevels have any business in an ICU.
 
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This is a conversation for your DIO to be having with your program director and Chairman. Not sure why they would even be including you at this point. It's not really up to the residents, it's up to the program.


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SouthernSurgeon said:
1) Strongly agree with the above, that this is way above your pay grade. I'm not sure why the head of the PA group is emailing the chief residents about this. This is a conversation between the director of GME/DIO and the PD/chair of your department.

2) That said, since you are looped into these conversations, I would strongly recommend that you start to inform yourself about the mechanisms of GME funding. Your department expanded 2 years ago - in all likelihood they did NOT receive additional federal funding to do that. GME funding has been capped by Medicare since 1997. Most of the times when departments expand, they have to make a financial argument to the hospital to justify that expansion. Sometimes that comes with Faustian bargains such as increased call/coverage responsibilities to make it worth the hospital's while. A good starting point for understanding these issues is the IOM report on GME funding (pdf free online)...I personally think their arguments for how to fix GME are FUBAR, but the report nicely summarizes how GME funding works.

3) Since you are looped in. Be an advocate for your fellow residents. The hospital wants you to take on this extra call because, regardless of federal funding or not, you (the residents) are the best deal they have. They pay you less than PAs and you work nearly double the hours. Throwing you in the ICU means they save a buttload. It doesn't mean it's in the best interests of your co-residents education.
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I'm likely missing something here. If those residents are already working max shifts elsewhere how does transferring them to icu save money?

Is the premise that thay work 60 now and will just add a icu shift?
 
SouthernSurgeon said:
1) Strongly agree with the above, that this is way above your pay grade. I'm not sure why the head of the PA group is emailing the chief residents about this. This is a conversation between the director of GME/DIO and the PD/chair of your department.
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In Medicine/Peds the Chief resident is usually a staff position that you take the year after residency, and they often get involved in staff level discussions, along with the PD.

sb247 said:
I'm likely missing something here. If those residents are already working max shifts elsewhere how does transferring them to icu save money?

Is the premise that thay work 60 now and will just add a icu shift?
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Odds are they are trying to pull residents from outpatient rotations where they would normally have weekends off. That's how my residency staffed our wards/ICUs on weekends, because my residentcy didn't believe in reducing staffing levels on weekends. That's also why my program's Interns only get two golden weekends in their entire Intern year.
 
Perrotfish said:
In Medicine/Peds the Chief resident is usually a staff position that you take the year after residency, and they often get involved in staff level discussions, along with the PD.



Odds are they are trying to pull residents from outpatient rotations where they would normally have weekends off. That's how my residency staffed our wards/ICUs on weekends, because my residentcy didn't believe in reducing staffing levels on weekends. That's also why my program's Interns only get two golden weekends in their entire Intern year.
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Wtf only 2 golden weekends? That is the worst schedule ever. Even in my workhorse program I've had a bunch of golden weekends
 
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HooliganSnail said:
You should have 21 days of vacation like everyone else......That is what CMS allows.
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Residency is based on ACGME regulations not CMS. ACGME doesn't mandate any specific amount of vacation, they just say that the individual GME needs to have a written policy about it. My program does 2 weeks of vacation for years 1-4 and 3 for 5-6 (because interviews take up vacation days). But we do get an extra 5 days off at Christmas or New Years that is not an institutional thing, just a benefit privilege that the department gives us on the side.
 
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A few thoughts:

When you say "we declined", who is we?

Are your residents violating duty hours?

This is not COR level discussion. Where is your PD?

You sound like you see yourself as a resident rather than junior faculty.

Residents during the week and PAs on the weekend isn't a common thing.
 
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When I was a resident, I took call Q5 and also every 4th or 5th weekend (Fri, Sat nights) in internship yr cuz we had 5 interns. Then, I took call Q8 cuz we shared senior call but took whole weekend ( yep, Fri, Sat and Sun round the clock) call up to 7-8 times a year. I thought this was a lot compared to programs that had more residents to cover the same number of days.
 
Thats too bad. I feel you. Happens everywhere. Midlevels pocket the big bucks, do as little work as possible, and spend their ample spare time petitioning for residents to take over as many responsibilities as possible. meh...
 
Perrotfish said:
In Medicine/Peds the Chief resident is usually a staff position that you take the year after residency, and they often get involved in staff level discussions, along with the PD.
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I'm going to be a chief in less than 2 months, but if I got an email at any point next year demanding that my residents work more than they already do (and likely changing the structure of rotations because of it), I would most certainly be looping my PD into that discussion. Our PD backs up the Chiefs for just about anything they want to do, but I would feel that I need backup for that type of discussion. We are changing up how everyone's schedule works next year, and there were multiple discussions between the current Chiefs, our PD and aPD, and the rising chiefs about what those changes should entail.
 
LucidSplash said:
Residency is based on ACGME regulations not CMS. ACGME doesn't mandate any specific amount of vacation, they just say that the individual GME needs to have a written policy about it. My program does 2 weeks of vacation for years 1-4 and 3 for 5-6 (because interviews take up vacation days). But we do get an extra 5 days off at Christmas or New Years that is not an institutional thing, just a benefit privilege that the department gives us on the side.
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Yes, but CMS pays the bills. CMS funded residency spots allocate 21 days of vacation. It is purely a money thing for them. At least that is what our hospital has told us since we were interns. My Med Ed are decent people, they were always about us actually taking vacation. Certain rotations (ICU) don't allow you to take time off, and you can only use so many per rotation, so they always grill into us the need to actually use our vacation time earlier in the year, and not get stuck with 7-8 unused vacation days at the end of the rotation.

ACGME just does the accrediting. Kinda like JACHO does the accrediting, and CMS does the paying. CMS actually pays per resident per month to the facility that actually has that resident. The allocated 21 days per year is their upper limit for full payment (they don't want to pay for people to not be at work...) This is why most programs HATE when you do out rotations, because the money goes with the resident.

Now if a program decides NOT to give you your full 21 days of vacation, that is allowed per ACGME rules, it just makes them D*cks.
 
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Raryn said:
Programs vary between 2 and 4 weeks of vacation over the course of the year.
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But never more than 21 days.....because that is what CMS mandates is the upper limit, or they withhold money.

These are important points for students to consider that most never realize until they are already residents.

I think if the hospital will get full payment and allow their residents 21 days off, but has a policy which allows LESS than that, it says alot about the type of program you are applying for.

Culture is huge in residency programs. The units/floors need to be covered, the residents need to be in the hospital to learn, but there is a rampant culture of well.....abuse that permeates a lot of programs. This is just one small example of that thing.
 
HooliganSnail said:
But never more than 21 days.....because that is what CMS mandates is the upper limit, or they withhold money.

These are important points for students to consider that most never realize until they are already residents.

I think if the hospital will get full payment and allow their residents 21 days off, but has a policy which allows LESS than that, it says alot about the type of program you are applying for.

Culture is huge in residency programs. The units/floors need to be covered, the residents need to be in the hospital to learn, but there is a rampant culture of well.....abuse that permeates a lot of programs. This is just one small example of that thing.
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Not all residents are paid by CMS. Many are paid out if hospital funds, medicaid dollars, VA money, etc. Hell, no peds residents get CMS money at all, they have a completely separate funding system.

And do recall that only the weekdays count as vacation. My program gives me 20 days of vacation a year. If I take them in one week chunks, our policy is to avoid work the weekend before and after assuming we can make the call schedule allow for it. So that can be up to 36 actual days of "vacation".
 
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HooliganSnail said:
Yes, but CMS pays the bills. CMS funded residency spots allocate 21 days of vacation. It is purely a money thing for them. At least that is what our hospital has told us since we were interns. My Med Ed are decent people, they were always about us actually taking vacation. Certain rotations (ICU) don't allow you to take time off, and you can only use so many per rotation, so they always grill into us the need to actually use our vacation time earlier in the year, and not get stuck with 7-8 unused vacation days at the end of the rotation.

ACGME just does the accrediting. Kinda like JACHO does the accrediting, and CMS does the paying. CMS actually pays per resident per month to the facility that actually has that resident. The allocated 21 days per year is their upper limit for full payment (they don't want to pay for people to not be at work...) This is why most programs HATE when you do out rotations, because the money goes with the resident.

Now if a program decides NOT to give you your full 21 days of vacation, that is allowed per ACGME rules, it just makes them D*cks.
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I don't claim to be all-knowing on this subject. But there are programs that give more than 3 weeks of vacation and I can't find documentation of the rule you state on the internet. I do know of at least one program that gave 4 weeks of vacation; however for interns it kinda sucked because they would randomly assign the vacation as a 4-week block. My friend basically had all of August off but no vacation the rest of her intern year. Therefore I surmise that if such a CMS rule exists limiting reimbursement to 3 weeks, it has nothing to do with what is recommended or allowed. It's just a financial cap. Therefore GME offices are free to make policy based on ACGME requirements. And vacation time can be subject to the needs of the institution/program. I disagree that getting less than 3 weeks makes a program d*cks.

Perhaps we can get @aProgDirector to weight in?
 
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What is this vacation thing you guys are discussing?

Back in my day we didnt take days off, we were fortunate to take naps!
 
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LucidSplash said:
I don't claim to be all-knowing on this subject. But there are programs that give more than 3 weeks of vacation and I can't find documentation of the rule you state on the internet. I do know of at least one program that gave 4 weeks of vacation; however for interns it kinda sucked because they would randomly assign the vacation as a 4-week block. My friend basically had all of August off but no vacation the rest of her intern year. Therefore I surmise that if such a CMS rule exists limiting reimbursement to 3 weeks, it has nothing to do with what is recommended or allowed. It's just a financial cap. Therefore GME offices are free to make policy based on ACGME requirements. And vacation time can be subject to the needs of the institution/program. I disagree that getting less than 3 weeks makes a program d*cks.

Perhaps we can get @aProgDirector to weight in?
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So I just went through the institutional, common program, and a couple specialty requirements just to see what the ACGME says. While there are clear guidelines stating a maximum of time off for each year, the only other requirement is that your vacation policy should be spelled out in your contract. They are otherwise silent on the subject. (There's also a random clause in the IM requirements that vacation time doesn't count towards your "must have a continuity clinic every X days" but that's mostly unrelated)

Everywhere I know, it's typically a minimum of 2 weeks and a max of 30 days, though there might be some interspecialty variability. Scheduling is program dependent. Some require you to take it all as one block, some only allow one week blocks or two week blocks. Some allow you to take it as individual days here and there piecemeal.

This thread is the first I ever heard of any CMS rule and CMS funding is incredibly complex, so I wouldn't really worry about it too much.
 
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HooliganSnail said:
Yes, but CMS pays the bills. CMS funded residency spots allocate 21 days of vacation. It is purely a money thing for them. At least that is what our hospital has told us since we were interns. My Med Ed are decent people, they were always about us actually taking vacation. Certain rotations (ICU) don't allow you to take time off, and you can only use so many per rotation, so they always grill into us the need to actually use our vacation time earlier in the year, and not get stuck with 7-8 unused vacation days at the end of the rotation.

ACGME just does the accrediting. Kinda like JACHO does the accrediting, and CMS does the paying. CMS actually pays per resident per month to the facility that actually has that resident. The allocated 21 days per year is their upper limit for full payment (they don't want to pay for people to not be at work...) This is why most programs HATE when you do out rotations, because the money goes with the resident.

Now if a program decides NOT to give you your full 21 days of vacation, that is allowed per ACGME rules, it just makes them D*cks.
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there are many programs out there that don't give 3 weeks of vacation...the minimum was 2 weeks...the max 4 weeks...as it has been said before its program dependent and i would imagine the programs has checked to see if their policies violate any rules.
 
HooliganSnail said:
But never more than 21 days.....because that is what CMS mandates is the upper limit, or they withhold money.

These are important points for students to consider that most never realize until they are already residents.

I think if the hospital will get full payment and allow their residents 21 days off, but has a policy which allows LESS than that, it says alot about the type of program you are applying for.

Culture is huge in residency programs. The units/floors need to be covered, the residents need to be in the hospital to learn, but there is a rampant culture of well.....abuse that permeates a lot of programs. This is just one small example of that thing.
Click to expand...

ACGME sets the limits for residency programs...the most you can miss per year is 1 month without having to make up the time.
 
LucidSplash said:
I don't claim to be all-knowing on this subject. But there are programs that give more than 3 weeks of vacation and I can't find documentation of the rule you state on the internet. I do know of at least one program that gave 4 weeks of vacation; however for interns it kinda sucked because they would randomly assign the vacation as a 4-week block. My friend basically had all of August off but no vacation the rest of her intern year. Therefore I surmise that if such a CMS rule exists limiting reimbursement to 3 weeks, it has nothing to do with what is recommended or allowed. It's just a financial cap. Therefore GME offices are free to make policy based on ACGME requirements. And vacation time can be subject to the needs of the institution/program. I disagree that getting less than 3 weeks makes a program d*cks.

Perhaps we can get @aProgDirector to weight in?
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There are programs that give 4 weeks of vacation. A lot of programs. Raryn is right. 20 days is 4-5 day weeks. I know its a foreign concept to most of us that weekends don't count as "workdays" for most people ;)
 
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Raryn brings up a good point. There are specialty specific requirements. I know that in general surgery the ABS has requirements requiring 48 weeks of clinical work each year to be considered eligible for board certification at the end of residency. Filling out my recent application I had to literally account for all of the time in my residency. This means that I also had to document any time away from residency more than 48 hours parentheses i.e. a standard weekend of call). Is included vacations conferences etc. It was painful. But they are not joking around with that stuff.
 
The American Board of Anesthesiology also has requirements as to how much time you can take away from your program before having to extend your residency. I believe that most boards have similar requirements. Some are more lenient than others. In regards to that CMS rule, according to our Government Finance people, that is how they have to figure stuff; that they are only getting 48 weeks of productivity out of you. Your institution may give you 5 weeks off, or 2 weeks, but when it comes to the CMS funding, their formula is stuck at 48 weeks.
 
Looks like y'all have answered the question without my help. Vacation time is not mandated by the ACGME, other than the institutional requirements which simply state that it needs to be spelled out in policies and contracts. Vacation is at the discretion of a program. ABMS boards often have specific rules about vacation. The ABIM, for example, limits to 1 month per year missed for vacation or any other reason -- hence we offer 3 weeks of vacation and then 5 sick or personal days. I don't know whether vacation days "count" for CMS funding or not -- but in any case, makes a very small difference. Programs also vary as to how accommodating they are to resident requests for time off, and how that time off is divided.
 
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Raryn said:
Not all residents are paid by CMS. Many are paid out if hospital funds, medicaid dollars, VA money, etc. Hell, no peds residents get CMS money at all, they have a completely separate funding system.

And do recall that only the weekdays count as vacation. My program gives me 20 days of vacation a year. If I take them in one week chunks, our policy is to avoid work the weekend before and after assuming we can make the call schedule allow for it. So that can be up to 36 actual days of "vacation".
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How deluded are your if you have been duped into thinking our your weekends as vacation
 
Psai said:
That schedule takes a special kind of cruelty to invent
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We are given week blocks off in certain rotations. My intern year, they gave me a week in July, a week in August, and a week in January. I was ready to kill someone by the end of the year.
 
Back in my prelim IM year days (15 years ago), vacation was a 1 month block...which meant that one person indeed did have their first month be vacation. I don't recall, as I was on vacation in November, where I was interviewing for EM, and went to Tahiti.
 
Light at end of tunnel said:
What happens if you take sick days?
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We don't get sick days. If we called out for some reason, we would either miss clinic, or someone would have to cover us. On wards during the day, that usually meant that the other interns split up your patients. At night or in the ED, that meant that the person on call was called in, and you were expected to pay them back. I have two or three people who still owe me shifts...
 
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azmang108 said:
I dont think midlevels have any business in an ICU.
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They're actually great to have around so long as there is an attending to back them up and they're trained in procedures. At a major ICU, they did all of the central/arterial lines and worked 7-5 while attending coverage was available, allowing our attendings and residents to cover more patients and giving the residents more time for learning instead of writing order changes, calling social workers, and doing other scut.
 
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DrBowtie said:
My intern year didn't have any sick days built in. Just used a jeopardy system for coverage.
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mvenus929 said:
We don't get sick days. If we called out for some reason, we would either miss clinic, or someone would have to cover us. On wards during the day, that usually meant that the other interns split up your patients. At night or in the ED, that meant that the person on call was called in, and you were expected to pay them back. I have two or three people who still owe me shifts...
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Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.
 
Light at end of tunnel said:
Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.
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The work has to be done, with or without you. Your co residents would have to cover for you missing a day. If you are on call, then they have to cover your call.
 
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Light at end of tunnel said:
Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.
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It's pretty much how many small practices are arranged, so even though it sucks in residency, it's kind of reasonable in a smaller program or one in which there isn't enough coverage if someone is out for a day. If you've got, say, five people providing ICU coverage in the community and one of you is sick, somebody has to cover, and usually you'll cover a shift for them to make up for it down the line. Medicine isn't like retail or something where you can just pick up the slack of a person that's out (most of the time). There's work that needs to be done, and someone needs to be there to do it.
 
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Light at end of tunnel said:
Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.
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Wondering what you'd suggest instead? If someone who is out ill has work that has to be done that day, then someone else needs to do it.

In my own clinical life, if I've got a day full of patients and cancel due to illness, anyone not critical gets bumped. But I have very minimal openings in my schedule -- so that means that I end up overbooking those patients over lunch, my admin time, or sometimes into the weekend to get them all seen.

In my program, we have "backup call". If you're on backup, and someone gets sick, then you get pulled to cover their shift if needed. Sometimes we can get away with not replacing the person (commonly, we can function without an intern on a team for a day). We don't mandate payback, we assume that, in general, the number of times any person calls in sick and the number of times they get pulled for backup for someone else will balance out. But it doesn't -- some people seem to call in sick more than others. Whether that's because they are "more ill" or because they "have a lower threshold to call in sick" is unclear. Or maybe it's just random. But having no payback creates some friction if you get called in quite a bit for someone else who doesn't "seem sick".
 
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