Introducing myself-I am an Internal Medicine PGY3 in the South.

[sandy616]

Looking forward to interacting with you all.

---

Members don't see this ad.

 

[sandy616]

One question I have is What's the rule on floor rotation without an intern for PGY3 ? My program signed a contract with a hospital that just started an internship last session and we as third years are to work and supervise the interns on their floor. However, they fired one of their interns who they have given multiple warnings. This hospital is superbusy and out of town rotation for us. Now, they want us to work without an intern for entire 3 weeks and are trying to negotiate on how many patients the resident will have to manage on his own. I am lost on what to do as it limits my ability to study for the boards. Will really appreciate any inout/guidance. thanks

 

[rokshana]

One question I have is What's the rule on floor rotation without an intern for PGY3 ? My program signed a contract with a hospital that just started an internship last session and we as third years are to work and supervise the interns on their floor. However, they fired one of their interns who they have given multiple warnings. This hospital is superbusy and out of town rotation for us. Now, they want us to work without an intern for entire 3 weeks and are trying to negotiate on how many patients the resident will have to manage on his own. I am lost on what to do as it limits my ability to study for the boards. Will really appreciate any inout/guidance. thanks

I doubt they can “negotiate “ the pt census for residents…ACGME is pretty specific about that and to do otherwise would be an ACGME violation.
Would imagine it can’t be more than what an individual resident can have on a service…5 new and 10 total.

 

[sandy616]

Thanks for answering my question. Could you explain 5 new , 10 total ? I suppose 10 is the cap.

 

[collegestud2013]

One question I have is What's the rule on floor rotation without an intern for PGY3 ? My program signed a contract with a hospital that just started an internship last session and we as third years are to work and supervise the interns on their floor. However, they fired one of their interns who they have given multiple warnings. This hospital is superbusy and out of town rotation for us. Now, they want us to work without an intern for entire 3 weeks and are trying to negotiate on how many patients the resident will have to manage on his own. I am lost on what to do as it limits my ability to study for the boards. Will really appreciate any inout/guidance. thanks

Look through the ACMGE rules for IM residencies (https://www.acgme.org/globalassets/pfassets/programrequirements/140_internalmedicine_2020.pdf). Looks like, it's 20 patients per day if it's 1 resident + 2 more more interns, or 14 patients if its just 1 resident + 1 intern. This doesn't include cross coverage situations like nights or even weekends though. Otherwise it's an ACGME violation and someone could report the program for it.

 

[sandy616]

Thanks, the situation is : they fired an intern and are now asking me to work without an intern. I do not know what the cap is or is it legal for them to make me work without an intern by saying we will lower the cap to 12 from 14 since you have no intern.

 

[NotAProgDirector]

First, there is no "legal" issue here. There are ACGME rules which the program must follow. But in emergency situations, the ACGME is often flexible. And, complaining to them about issues is a slow process that is unlikely to help with this upcoming issue.

Based on the rules, they can absolutely have you take care of 14 patients. In fact, there are no rules about what a resident by themselves can do, so they could theoretically give you more. They could argue that the educational rationale is that they want you to experience the workload of a hospitalist. if they are offering to decrease the cap from 14 to 12 because there's no intern -- you take that and call it a win.

 

[sandy616]

well if that's within the rule then I have to. My program signed up a contract with them in our third year to do 2 floor rotations as third year to supervise their interns as they just started a training program. They have put an intern on non teaching team with a non teaching attending and asking me as a resident from another program to suck it up. If I have no option left then I want to follow ACGME rule on caps.

 

[sandy616]

First, there is no "legal" issue here. There are ACGME rules which the program must follow. But in emergency situations, the ACGME is often flexible. And, complaining to them about issues is a slow process that is unlikely to help with this upcoming issue.

Based on the rules, they can absolutely have you take care of 14 patients. In fact, there are no rules about what a resident by themselves can do, so they could theoretically give you more. They could argue that the educational rationale is that they want you to experience the workload of a hospitalist. if they are offering to decrease the cap from 14 to 12 because there's no intern -- you take that and call it a win.

How can they argue that the resident should have hospitalist workload when the latter varies with the hospital, is 7 on 7 off, pays 300K more and you are not a trainee protected by ACGME but willingly signed up a contract accepting their cap.

 

[rokshana]

well if that's within the rule then I have to. My program signed up a contract with them in our third year to do 2 floor rotations as third year to supervise their interns as they just started a training program. They have put an intern on non teaching team with a non teaching attending and asking me as a resident from another program to suck it up. If I have no option left then I want to follow ACGME rule on caps.

Well actually the intern would actually have the beef here…trainees can’t see pt on a non teaching service.

 

[rokshana]

How can they argue that the resident should have hospitalist workload when the latter varies with the hospital, is 7 on 7 off, pays 300K more and you are not a trainee protected by ACGME but willingly signed up a contract accepting their cap.

Lol… I would have thanked God for a census of 14, never mind 12! This is far from a hospitalist load.

You are THREE months away from being an attending…take this opportunity to start getting used to being an attending… it’s the half glass full outlook.

 

[NotAProgDirector]

Well actually the intern would actually have the beef here…trainees can’t see pt on a non teaching service.

Once you put an intern on the service, it's now a teaching service. The "non teaching" rule is that residents shouldn't be cross covering non teaching patients. Non teaching services need their own nocturnal and weekend coverage.

 

[NotAProgDirector]

How can they argue that the resident should have hospitalist workload when the latter varies with the hospital, is 7 on 7 off, pays 300K more and you are not a trainee protected by ACGME but willingly signed up a contract accepting their cap.

Because you still are supervised. Someone will be checking your work.

My point simply is that if as a resident you only care for 8-10 patients at a time and then you go out to your first job and have 16 patients, it could be a rude awakening. One could argue that we should have residents working in their final year at a similar workload as a hospitalist. If I were to do this I'd make it 7 on / 7 off (or board study, research, etc, since ABIM limits amount of time off you can have).

 

[sandy616]

Lol… I would have thanked God for a census of 14, never mind 12! This is far from a hospitalist load.

You are THREE months away from being an attending…take this opportunity to start getting used to being an attending… it’s the half glass full outlook.

Already worked with more than 14 patients since the attending told me ACGME has no CAP. 14 is an ACGME cap , hard to argue against that. Our program lost accreditation because interns reported they saw more than 10 patients , this can nt be done. May be you worked in NYC community hospital that treat you as a cheap labor. Programs have to manage the workload and educational activities.

 

[sandy616]

Well actually the intern would actually have the beef here…trainees can’t see pt on a non teaching service.

so I thought but hospitals exploit people...not just intern but also medical students, and use some medical students as intern

 

[chessknt]

Dude what is the point of this entire pile of nonsense? You're almost done and you don't ever have to deal with these people again, why throw a giant tantrum right before you are about to walk out the door? What are you hoping to accomplish?

 

[rokshana]

Already worked with more than 14 patients since the attending told me ACGME has no CAP. 14 is an ACGME cap , hard to argue against that. Our program lost accreditation because interns reported they saw more than 10 patients , this can nt be done. May be you worked in NYC community hospital that treat you as a cheap labor. Programs have to manage the workload and educational activities.

No…not talking about being a resident …ask anyone that works as a hospitalist…the average census is typically 18-20 if you are a rounder and sometimes at places that don’t have dedicated admitters, you admit as well…
I trained at a university program in Georgia… they followed all the ACGME guidelines…

You are in for a rude awakening in a few short months if you think as a hospitalist, you will only have 12-14 pt on your census

 

[rokshana]

so I thought but hospitals exploit people...not just intern but also medical students, and use some medical students as intern

Lol…sounds like you are the one that works for a program that exploits its trainees for cheap labor…

 

[CCM-MD]

The more you F around, the more you'll find out. I personally know a PGY3 who was fired. Your program holds all the cards. Keep your head down, finish your residency and move on.

 

[collegestud2013]

so I thought but hospitals exploit people...not just intern but also medical students, and use some medical students as intern

Yup, and it has gotten worse since the pandemic started and with more hospitals in the red and with understaffing issues. Interns/residents are the easiest targets since their duty hours can be increased all the way up to the ACGME limit without having to pay them any more. Probably the best you can do as a trainee is avoid and not match into those programs in the first place. Some of the better funded hospitals may at least turn it into a paid moonlighting opportunity, but the more malignant programs may just cut out elective blocks down to the bare ACGME mandated minimum and increase inpatient service blocks.

 

[collegestud2013]

No…not talking about being a resident …ask anyone that works as a hospitalist…the average census is typically 18-20 if you are a rounder and sometimes at places that don’t have dedicated admitters, you admit as well…
I trained at a university program in Georgia… they followed all the ACGME guidelines…

You are in for a rude awakening in a few short months if you think as a hospitalist, you will only have 12-14 pt on your census

Argument could go both ways here. On one had it's better to get used to the typical hospitalist attending census ahead of time than have surprises on your first job. On the other, as OP has alluded to, he feels he may be exploited to do more work since he is paid a flat salary as a resident and does not get RVUs/productivity pay like the attending does.

It's also possible that OP is not going into hospital medicine in the first place and is just using IM residency as a stepping stone to another subspeciality. In residency, these were the people who did not care at all about the inpatient floors rotations and just wanted to do the least amount of work possible. This was especially the case for the prelim interns (especially the ones going to fields like radiology, dermatology, anesthesiology, that were very different than IM).

Workload can also vary a lot across different places for the same census. If his hospital is closer to a typical NYC hospital with minimal ancillary staffing and a lot of the work falling on the residents, seeing 12-14 patients could be as much work as seeing 18-20 in a full staffed hospital with full subspeciality support.

 

[gutonc]

The more you F around, the more you'll find out. I personally know a PGY3 who was fired. Your program holds all the cards. Keep your head down, finish your residency and move on.

View attachment 369165

I think it's more logarithmic than linear. The F* around input doesn't need to be much for a very high "find out" response. Eventually it plateaus, but by then it's far too late.

 

[sandy616]

Dude what is the point of this entire pile of nonsense? You're almost done and you don't ever have to deal with these people again, why throw a giant tantrum right before you are about to walk out the door? What are you hoping to accomplish?

Our program was under probation coz someone reported they violated ACGME rules eventhough they had not. This program i am rotating at is a new site for PGY3 only and they violate ACGME rules, my program wont take it that far. So, next year the guys would have better luck. If you do not fight back the program only gives u the raw end of the deal. Those residents who pushed back, they do not get bothered by anyone. I think there should be uniform rules for all and programs should follow ACGME rules unless they do not care about accreditation and let residents know beforehand.

 

[dozitgetchahi]

Our program was under probation coz someone reported they violated ACGME rules eventhough they had not. This program i am rotating at is a new site for PGY3 only and they violate ACGME rules, my program wont take it that far. So, next year the guys would have better luck. If you do not fight back the program only gives u the raw end of the deal. Those residents who pushed back, they do not get bothered by anyone. I think there should be uniform rules for all and programs should follow ACGME rules unless they do not care about accreditation and let residents know beforehand.

Again, as a resident you have very little control over anything and are extremely vulnerable. While I do respect your desire to stand up and make institutions follow rules, just know that as a trainee you have about as much power as a detainee at Gitmo. Shut up, do your time, and get out.

 

[sandy616]

Again, as a resident you have very little control over anything and are extremely vulnerable. While I do respect your desire to stand up and make institutions follow rules, just know that as a trainee you have about as much power as a detainee at Gitmo. Shut up, do your time, and get out.

Agree. I wont risk it, I will complaint after I graduate so others do not have to face these exploiting conditions or atleast are aware they have to when they sign up with that program

 

[NotAProgDirector]

You are absolutely welcome to submit any report to the ACGME that you would like. As stated here already, the ACGME rules for a PGY-2+ would be a cap of 14 patients, with or without an intern. If they ar egiving you less than that, then there is no violation.

 

[sandy616]

I doubt that is the case. ACGME has no policy stated on their site so no one knows what's the cap. If 1 intern 1 resident team has a cap of 14 then I doubt, it would be 14 for a resident alone.

 

[thumbz]

There's no set rule for a resident alone. We as faculty have debated this for eons at our program and try to follow the spirit of the ACGME.

On a 2 intern team the cap is 20, and the interns have a day off. At many program it's a day off together. And then their senior rounds on the list of 20. At my program attendings often chip in to help write notes, but I can promise you this isn't true at other places, including where I did wards as a med student (and watched my seniors round on 20 patients on their post call intern off day).

On a 1 intern team you're guaranteed solo senior days and the senior can, and should, cover the whole service (which is 14). Most programs use this to extrapolate to having seniors cap out at 14.

On subspecialty services all bets are off. ID services are a great example. There may be a list of 30, but 1/2 of them are chronic IV abx and are one liner notes. What's the ACGME's take on this? No clue.

As someone who works at a historically "lighter" program I can tell you the biggest feedback we get post graduation is the learning curve the first time they have a list of 22 and no attending to ask questions of, and no interns to write notes.