Subject: I unbundle
My Residency recently converted
to a PM&S 36. During the Site Visit from CPME, I was told by one of the CPME
team members that we were unbundling our cases. I pressed him further and he
said that in the case of an ankle fracture, that a fib fracture ORIF vs a Bi-
malleolar ORIF vs a Tri-malleolar was all the same and could only be logged
once. I am with you that you are addressing separate fractures and different
bones with different surgical principles for each. This is a definite gray area
that should be addressed by CPME.
I continue to do this type of
"unbundling" routinely and would challenge anyone to argue the facts as stated
above.
Keep up the good work!
Michael J. Hattan, D.P.M.
Long Beach Memorial Medical Center
Department of Podiatry/Orthopaedic Surgery
Foot and Ankle Reconstruction Surgery, Senior Resident
Mwhattan@aol.com
Editor's Response
Michael, I agree with your confusion. In that specific
instance, I would want to log it as 2 procedures (if I didn’t have to fixate the
posterior malleolar fragment) and 3 if I did. However, as I’m sure you’re aware,
the manner in which Residency Resource lists this procedure (Open repair of
adult ankle fracture) leads one to believe this should be logged as one
procedure. Again, more ambiguity in our logging.
- Jarrod
Subject: CPME vs ABPOPPM, who has
jurisdiction on case logging?
Some good thoughts about the logging
process. You mention only the problems with surgical logging, and that is not to
mention the non-surgical logging. Whenever I have asked anyone at CPME about
proper logging, the only thing they will do is refer me to the boards. Our
program has in the past been monitored by ABPOPPM, however they have a category
of procedures (category 9) in the logging procedure that has no way of being
reported on our annual reports to CPME.
To say the least, the Boards have given
poor instructions on how to properly log, yet CPME is deferring all questions to
them. Now that we are going to make the conversion this next year to a
comprehensive program, which board do I call about logging? CPME hasn't informed
me about that yet.
And if you want to raise another
interesting question, why don't you try to figure out why MVAs are set at their
stated levels? I had the audacity to ask once, "Why does it take more hammertoe
surgeries in residency to become proficient, than it does bunion surgeries?" To
say the least, the answer would make any politician in Washington, D.C. proud.
Best wishes to you.
Robert D. Phillips, D.P.M.
Coatesville VAMC
Robert.Phillips2@va.gov
Subject: The MDs have a better
way
- Use CPT Billing Codes
It is my personal opinion to scrap the
entire logging system and adopt a system similar to that of the MD logging
system.
They use the same code for their logs
as they do for their billing or procedure codes. This is beneficial on multiple
levels and you are not bound by a ridiculous list of procedures that cannot
begin to apply to every procedure we perform.
I hate to break this to those who
developed this cumbersome system, but some of us are doing more than just
bunions. And some of us have more than enough procedures so as to not have to
worry about whether this triple is broken up into 3 procedures or not.
It is hard to convey all of the
frustration through a simple e-mail, but I assume I am not the only one who
feels this way.
Out with the old and in with the new.
We hold ourselves back by dwelling on problems like incorrect logging in an
inadequate logging system. Thank you for your time,
Jason Anderson, PGY 1
The Kentucky Podiatric Residency Program at Norton Audubon Hospital
anderjas99@yahoo.com
Editor's Response
You have an interesting idea, and you’re not the only one to
be frustrated. The high level of responses to this topic is evidence to that
fact. In regards to your proposal, if you speak to physicians about billing,
they’ll usually tell you they still have problems with the system (besides not
being paid enough). I have heard of some confusion regarding coding for certain
multiple procedure cases such as Austin-Akins. My concern is that this might not
eliminate the confusion for us residents. Having said this, I think any clearly
defined logging system, whatever it is, would be an improvement, as long as it
accurately reflects our education.
-Jarrod
Subject: I'd just like to know
the rules
I agree with your recent analysis of
logging procedures. For 4 years now, I have been told by various people that
this procedure is one and that procedure is 2, etc. But when I dare to ask if I
can see the manual on logging, no one can produce it. Even when we were visited
by the council, when I was a first year, they said that we were over-logging.
Again, I respectfully asked, “Is there a manual on correct logging procedures ?"
They answered, no not yet. What kind of answer is that? Until they come out with
hard and fast guidelines, I agree with logging every procedure as a separate one
with detailed notes. Thanks for letting me vent. Sincerely,
Victor J. Quijano Jr. DPM, PhD
4th year resident
Temple University Hospital
Philadelphia, PA
vicdoubledoc@excite.com
Subject: Response from the JRRC
Chair
In reference to your statement " If you
take a look at the CPME 320 document, you won't be able to find any solid
information about how to log cases. If you look anywhere else, you still won't
find any clear information." I would suggest you "look" at
http://cpme.org, under the header Residencies, you
will find JRRC 671 (sample), Clinical Report Log (Sample). This sample clinical
log has been developed by the Joint Residency Review Committee (JRRC) to assist
residents and Directors of Podiatric Medical Education in proper logging.
Additionally, the Council staff is readily available to respond to inquiries
from its community of interest. It is the responsibility of the Director of
Podiatric Medical Education to review and validate residents’ clinical logs at
least quarterly.
In reference to your statement "First,
I'm told the CPME meets 2 times per year. How can anything of significance be
decided on with 2 sessions a year?" The Council does meet twice per year as does
all of its committees. Particularly, the JRRC meets in March and September with
each meeting conducted for three to four days. As part of its meeting the JRRC
discusses numerous agenda items for which the community of interest may attend.
At its meetings the JRRC also reviews reports of recent on-site residency
reviews, progress reports, and requests for increase of approved positions. In
addition to these scheduled meetings, the JRRC conducts numerous mail ballots
and conference calls.
In the future I would suggest that
before you write your editorials that you obtain accurate information.
Thank you,
Stuart Wertheimer DPM
Chair, JRRC
Stuart.Wertheimer@stjohn.org
Editor's Response
Thank you for your response. It adds another facet to the
debate and might clear up discrepancies we residents don’t understand. I’d like
to respond to your comments separately.
At your urging, I did review the
JRRC 671 sample. With due respect, after reviewing this along with
some of my co-residents, I’m no closer to understanding this issue than before.
This document is simply a list of some procedures and how they would be logged.
What we residents have been discussing is the lack of clear, well-documented
guidelines on logging. Perhaps you might enlighten us with the reference of a
specific document that formally lists in detail how to log these cases in
addition to the rationale behind the system?
My main contention has been that the logs should reflect the
educational content of that particular experience, which they currently do not.
In my opinion, the best way to do this is to log each procedure separately with
a note in the comments that it is part of a larger reconstruction. Hence, a
triple would be 3 procedures because the educational content is equivalent to
doing the procedures separately. I ask you, if this issue were clear, then why
are we hearing from so many confused people, including Residency Directors? I’d
refer you to Dr Brancheau’s comments above.
Finally, I don’t see any inaccuracy in what I’ve said. Your
comments above regarding the number of times the JRRC meets is consistent with
my statements: 2 meetings. You mentioned the concerned parties could attend. I’m
sure you don’t actually expect residents to attend these meetings? I do
acknowledge that a lot of work is accomplished “behind the scenes” via phone
conversations, etc. However, we still have a national resident (and attending)
community who don’t know exactly what to do. I don’t think this is an
excessively complex issue, but I’d recommend sampling the resident community and
listening to our concerns to obtain a true picture of the dilemma.
-Jarrod
Subject: I don't bundle
I understand the frustration of many
residents with the unclear guidelines set forth on the appropriate logging of
surgical cases. With that said, I don’t agree that a triple arthrodesis is three
procedures. I don't agree that a pan metatarsal head resection is 4 procedures.
Residents logging in this fashion are misleading what their surgical experience
and volume really is. If you follow that line of reasoning, then a bunion would
also include a tenotomy if you released the EHB and a MPJ capsule balancing if a
medial capsulorraphy is performed. In my opinion, it's all part of the bunion.
This can be taken even further. We do
many charcot reconstructions with Lisfranc fusions, TAL and exfix applications.
Should those cases count as 8-12 (4/5 met cuboid, 1/2/3 metcuneiform,
intercuneiform, possible TNJ, NCJ x 3, CCJ) midfoot fusions, with the addition
of a TAL and exfix application? I will grant the TAL is a separate procedure. My
point is a triple is A SINGLE SURGICAL PROCEDURE consisting of the fusion of 3
joints. The same goes for a pan met head resection. That is why the comment and
procedure note section allows you to document the extent of the case. As for the
flatfoot reconstruction, there is no single procedure known as a flatfoot
reconstruction. Each component may be incorporated to address the structural and
functional needs of that particular pt; therefore each is a separate procedure.
If you have explained the manner in
which most residents are logging procedures, perhaps a review of my logs is in
order. My experiences, those that reflect upon the volume of my program, have
been vastly underestimated.
Dr. Anonymous
Editor's Response
Excellent points! I agree and disagree with you. I completely
agree that there’s a risk of misrepresenting our surgical experiences. How much
of this happens now, though? This is why I think residents should optimally log
the individual procedures as part of a composite case with appropriate
documentation in the notes section. In reference to the bunionectomy example, I
agree that this could be dissected down ad infinitum. Logging should have some
reason behind it and not get ridiculous (hence my desire for formal reference
material by our leadership).
I’ll reiterate that the logs should reflect our educational
experience. If a resident can perform a triple arthrodesis, don’t you think they
can adequately complete an isolated subtalar fusion? The Charcot reconstruction
you mentioned should surely count for more than two procedures. This type of
complex reconstruction necessitates strong surgical and didactic knowledge to
successfully complete and should be given due credit. I’m sure you’re aware that
any resident in the country would log your example as several procedures rather
than two.
My statement regarding flatfoot reconstruction was simply an
illustrative example of the concept that each of the procedures should be
counted separately to document the educational experience. Residents simply want
a clear, straightforward, organized system that adequately represents our
training. If it were clear there wouldn’t be so much discussion.
-Jarrod
Subject: A definite problem
I could not agree more that there is a
lack of clear guidelines when it comes to logging surgical cases. I have two
additional concerns about logging as well. First, I question the way our logs
will ultimately be judged. When our program was reviewed to obtain PM&S 36
status, the reviewers questioned a case I had logged early in my second year in
which I completed a TMA as well as excision of 4 distinct skin lesions separate
from the site of amputation. I logged the case as a met head resection (only
one) as well as 4 excision of skin lesions. I described the nature and location
of each skin lesion on residency review. The reviewers assumed that I had simply
revised the flap from the TMA in four locations and marked that as an excision
of skin lesion each time. I stand by the way I logged the case, but I am
concerned that when our final logs are evaluated similar situations could
arise-particularly for people who do not explicitly describe procedures when
they log.
My second concern is about discrepancy
between how different programs' logs. At our program, we always log a triple as
one case as well as TMA's...etc. However, apparently other programs do not.
Additionally, I have debated when to log a 'C' vs a 'B' with residents from
other programs. At our program, we are careful to log c's only when we complete
the majority of a procedure, but I have heard others state that if residents
attend a case, one of them should get a C regardless of whether they retract or
complete the procedure skin to skin.
Thank you for your time, and thank you
for the residency rap issues. I have enjoyed hearing what other people are
thinking about some of the issues facing residents. Sincerely,
John Hewitt, DPM
United Health Services Hospital
John_Hewitt@uhs.org
Subject: There has to be an
easier way
In response to the 'Logging' issue of
Residency Rap, I am very frustrated with the new PM&S logging system. We now
have to log each clinic encounter as a separate patient, which is taking hours
to complete. There has to be an easier, more efficient way to log clinic
encounters. I feel that all residency programs need to give feedback to
Residency Resource on the extensive amount of time that this new logging system
is requiring. The previous way of logging clinic encounters was much more
efficient and should be considered as an alternative. Respectfully,
Meagan M. Lewis, DPM, Resident
Swedish Medical Center
mmlewis77@yahoo.com
Subject: What needs to be logged
?
I completely agree. A related issue is
what needs to be logged? How do I log every patient encounter, as some say we
need to do? I rounded on 5 people this morning, and then saw clinic patients.
Some were post ops, some general care, etc. Why do we need to log these?
Our PM&S goals need to be delineated-
to us (in writing). My director seems to know what numbers I need to achieve,
but I don't. I am referring to non-surgical patients.
What is your experience?
Brad Olson, DPM
Health Partners Institute/Regions Hospital
St. Paul, MN
Bradley.R.Olson@HealthPartners.Com
