Self-policing is the most effective way for a residency program to keep on the good side of the Accreditation Council for Graduate Medical Education (ACGME), according to an article in the July Journal of the American College of Radiology.
Staying on top of the ACGME requirements and keeping staff involved with residents are just a couple tools to avoid running afoul of the ACGME, according to Dr. Carol Rumack from the University of Colorado in Denver.
In another JACR article, Dr. Anu Bansal of Brigham & Women's Hospital in Boston examines the delicate balance between providing optimal patient care while still giving residents a chance to learn. Bansal suggests that the traditional "trial by fire" method employed by most educational facilities may be nothing more than "hierarchical hazing."
Avoiding ACGME citations
All diagnostic radiology residency programs must undergo review every five years by the ACGME, Rumack noted. Before these regulators show up at the door, Rumack advocated a midcycle internal review by an institution's graduate medical education committee (GMEC).
"An internal review is an opportunity to review new issues, such as duty hours and competencies that have been added to the requirements, and to check that changes in your program have not resulted in significant compliance issues," she wrote (JACR, July 2005, Vol. 2:7, pp. 617-621).
These compliance issues include:
- Poor performance on the ABR exams
- Insufficient ratio of resident-faculty ratio
- Failing to conduct annual, anonymous resident evaluations
- Night-float rotations
Remedies for poor exam numbers include rotations and conferences with mandatory resident participation and mock oral board exams. Rumack advised against allowing residents to take time off to study at home for the boards.
To maintain the student-to-teacher ratio, Rumack pointed out that a program can count all radiology faculty members, both physicians and nonphysicians, as resident supervisors as long as they teach on a regular basis. However, radiation oncologists cannot be counted.
Residents should create written evaluations of the program, she stated -- a conversation between a program director and the resident is insufficient. A separate evaluation assessing the curriculum for each specific rotation also needs to be done.
As for night-float rotations, Rumack acknowledged that they are useful for maintaining a high level of service in an imaging department. But she warned that that they also have a "high risk of interfering with residents' education." There is a danger that a resident taking night calls may have inadequate interaction with faculty and fellow residents. Rumack recommended that after a night call or float, a teacher and resident review all films and not just the ones that require revision.
24-hour attending
On the related topic of meeting the healthcare needs of the patient and the educational needs of the resident, Bansal examined the pros and cons of having 24-hour attending coverage.
"There is a constant (and appropriate) emphasis on improving patient care, and sometimes the easier way to accomplish this is at the expense of either research or teaching," Bansal wrote in a residents' column (JACR, July 2005, Vol. 2:7, pp. 642-644).
The arguments in favor of 24-hour attending service included eliminating errors commonly made by radiology trainees, as well as an improved rapport between radiology and other departments.
This system also offers residents an ongoing classroom where they are being taught by the overnight attendings throughout the shift. It also provides a "significant cushion" for a resident who might otherwise be working alone.
The most obvious downside of 24-hour attending coverage is the added cost. A more complex issue is whether it would deprive residents of learning on the job and gaining confidence in their own skills. However, Bansal said that his department's experience with 24-hour attending coverage has shown these concerns to be groundless.
At his hospital, three dedicated nighthawk radiologists were hired and the impact has been mostly positive. The residents said they have gained a better teaching experience as impromptu lectures are held during slow periods. The presence of the nighthawk radiologist has also decreased on-call hours for the residents and decreased "fear and uncertainty," according to Bansal.
But "all residents surveyed in my program stated that they felt a moderate to severe loss of independence," he added. Bansal questioned whether that independence was worth trading for a higher standard of patient care.
"By giving up some degree of independence, are residents really losing that important a part of their training?" he asked. "Teaching institutions still have a primary obligation to provide the best possible patient care."
By Shalmali Pal
AuntMinnie.com staff writer
July 20, 2005
Related Reading
Self-referral puts serious crimp in rad residents' educational experience, June 7, 2005
Radiology residents can accurately evaluate after-hours head CTs for stroke, May 20, 2005
Study asks: If residents snooze more, do patients lose out more? December 21, 2004
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