Is your program following ACGME Cap Rules?

[nolayup]

I go to a community IM program where we divide up all the patients between 3 teams. We do not have any non teaching teams. We also have an open ICU. We have consistently gone over ACGME cap rules especially for residents overseeing interns (14/20 per ACGME) long before the pandemic. Interns are generally at 10, however at times have been asked to chart review additional patients. We divide up all overnight admissions between the three teams and can hand off day admissions to the other 2 teams until noon.

With the pandemic, all three teams have been seeing 22-25 patients a day, on call days we are at the mercy of the ED and can see around 29-30 patients a day. I understand we are amidst a pandemic and I do appreciate the learning and ability to build stamina in seeing/supervising 29-30 patients. The general consensus at our program is that as seniors, we should be able to "deal with it" and that all other program are doing the same. I worry about patient safety as well. Curious to hear your thoughts?

Thanks

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[PugsAndHugs]

That’s BS in my opinion. They just don’t want to shell out the money for more providers to cover the extra patient. I’m at academic program in a hard hit area and they are keeping us at cap. (Granted there are many non-teaching teams)

 

[Splenda88]

I echo the above poster. Report them to ACGME.

 

[nolayup]

Just curious if the ACGME allows for caps rules to be broken during events such as a pandemic?

Some more history on this issue. This was actually brought up and even reported to the ACGME last year but not sure if anything resulted. As you can imagine, when seeing such a volume of patients, there is hardly any time for teaching etc. This is also another serious issue at our program.

Basically the hospitalists asked seniors what our definition of "supervising" the interns was and asked us to only chart review intern's patients and not physically see them and then to monitor intern's orders.... so essentially supervising interns. They did this in order to find a loop hole where the residents would not be considering going over cap as they would not be supervising interns. My main priority is excellent patient care and as mentioned, we find a way to deal with this issue at our program, but am always amazed when I hear some programs have caps below the ACGME which allows for more teaching time and other endeavors.

 

[Elixir6]

I would not try to engage with the program based on what you said because you could suffer blow back. Best to anonymously report it and encourage any trusted colleagues who would not rat you out to do the same.

This is detremental to your education, both interns and residents, and a serious patient safety issue. How can you judge the safety and appropriateness of care through chart review???? Whether this is due to finances or constraints on personnel this should not be dumped on you.

ACGME clearly states:

IV.C.3.g).(3) a first-year resident must not be responsible for the ongoing care of more than 10 patients; (Core)

IV.C.3.g).(4) when supervising more than one first-year resident, the supervising resident must not be responsible for the supervision or admission of more than 10 new patients and
four transfer patients per admitting day or more than 16 new patients in a 48-hour period; (Core)

IV.C.3.g).(5) when supervising one first-year resident, the supervising
resident must not be responsible for the ongoing care of more than 14 patients; (Core)

IV.C.3.g).(6) when supervising more than one first-year resident, the supervising resident must not be responsible for the
ongoing care of more than 20 patients; (Core)

 

[ShuperNewbie]

Holy... even during the pandemic we didn't go over cap. And this is in NYC... at an institution that famously got hit really hard during the pandemic

 

[TwistedTea]

Hard pass. Not only due to workload but just the lack of teaching. Sounds malignant

 

[nolayup]

So apparently, this program feels that if there is a 3rd year and 2nd year on the team, then there is room for interpretation in the ACGME cap rules as there are two supervising residents on the team. Therefore creating a "mega-team". But I still try to follow all patients. Perhaps, they may ask the 3rd and 2nd year to simply supervise one intern each up to 14 patients. To be honest, this drama is such an annoyance and petty.

Does this make any sense?

 

[Drrrrrr. Celty]

Nah. Supervising an intern for 10 and then writing 4-5 notes on your own is already a pain in the ass especially early in the year when you're doing your own physical pre-rounds on their patients as well is already kind of high exhaustion.

 

[Kaustikos]

I would not try to engage with the program based on what you said because you could suffer blow back. Best to anonymously report it and encourage any trusted colleagues who would not rat you out to do the same.

This is detrimental to your education, both interns and residents, and a serious patient safety issue. How can you judge the safety and appropriateness of care through chart review???? Whether this is due to finances or constraints on personnel this should not be dumped on you.

ACGME clearly states:

IV.C.3.g).(3) a first-year resident must not be responsible for the ongoing care of more than 10 patients; (Core)

IV.C.3.g).(4) when supervising more than one first-year resident, the supervising resident must not be responsible for the supervision or admission of more than 10 new patients and
four transfer patients per admitting day or more than 16 new patients in a 48-hour period; (Core)

IV.C.3.g).(5) when supervising one first-year resident, the supervising
resident must not be responsible for the ongoing care of more than 14 patients; (Core)

IV.C.3.g).(6) when supervising more than one first-year resident, the supervising resident must not be responsible for the
ongoing care of more than 20 patients; (Core)

That's the reality. It happened in March/April - and finding attendings/physicians to help cover wasn't gonna' happen, either. Not to mention colleagues/residents being out sick made things worse.
But, to be fair, a lot of our patients were SNF/AH patients with horrible prognosis that were dropping on a daily basis.

And then we come to nights where you had 6-8 codes/night and only 6-8 residents total covering.

Holy... even during the pandemic we didn't go over cap. And this is in NYC... at an institution that famously got hit really hard during the pandemic

That's vague . All NYC institutions got hit hard. I know Bronx/Queens were in close competition with each other.

Oh the memories this brings back!

 

[Elixir6]

That's the reality. It happened in March/April - and finding attendings/physicians to help cover wasn't gonna' happen, either. Not to mention colleagues/residents being out sick made things worse.
But, to be fair, a lot of our patients were SNF/AH patients with horrible prognosis that were dropping on a daily basis.

And then we come to nights where you had 6-8 codes/night and only 6-8 residents total covering.


That's vague . All NYC institutions got hit hard. I know Bronx/Queens were in close competition with each other.

Oh the memories this brings back!

No, your claim "that's the reality" doesn't make it correct or acceptable. If there was a disaster like the pandemic and shortages, and this was temporary, sure, I would say you need to suck it up to help patients and colleagues. But the poster specifically said this was going on "long before the pandemic".

The "reality” is most likely that the hospital is squeezing residents for financial reasons because the power differential is asymmetrical. This is exactly part of the role of the ACGME.

Additionally, patients "dropping like flies” need appropriate care. Would you want your mother in a hospital where residents were taking care of her like this, or attendings were responding, "Don't worry, although this resident is taking care of 30 patients, it's ok because many of the patients don't require much medical thought because they are actively dying”???

This isn't a pissing contest to see who is stretched more thin and can be most callous.

I have to say I'm not surprised though that our system is producing physicians and health care systems with these types of views.