Imminent termination, need serious advice!!!

[johndoe44]

Hey all,

So I am sure this story has come up but I never ever thought I would be typing this into this forum. Here it goes.

So I just started my PGY 2 year in Medicine. My intern year overall went very well. I had above average evaluation each month and all of my attending physicians and I appeared to have a good relationship. The comments after each evaluation would normally say mostly positive things but there occasionally were concerns about "needs to continue to improve fund of knowledge" and " needs to continue to read and improve" and " differential diagnosis skills improving." I am by no means the smartest resident nor am I perfect so I respected all of my attending physicians and took their advice to heart and I continued to improve with each month becoming better and more efficient.

Everything was going well from July 2013- April 2014. There was NEVER a single instant where I was alerted about areas that were concerning. There had already been 3 "committee" meetings up until that point and my name had never been brought up and I was never approached regarding any concerns. This was until I recently completed my ICU rotation which I thought was going a little bumpy but I was learning tremendously as I went along. I would see my patients, never late, never missed a day, never any danger to any patient's, great relationship with my upper level and my patients; so naturally I assumed I was doing okay and started my May ward month. I noticed about mid may when my ICU evaluations came in that they were significantly lower than any of my previous evaluations and they "ripped me" in the comments stating that " he needs to read; Lots of room for improvement; not at the level of his peers" and other such things. This was very concerning to me as I had not received any feedback or any notice from any ICU attendings that I was doing so poorly? I was so confused I went to my program director and just met with him to address my concerns and that I did not feel that I was evaluated enough to make such comments regarding my knowledge base. He was surprised and stated he would bring it up at the next meeting. No problem. In the meantime, I have signed my PGY 2 contract, I have my schedule, I have all my elective months to coincide with weddings, and everything was going well. Apparently, after the committee meeting my PD called me in and said that the ICU people and "others" ( I am not sure who was there) had some concerns about my knowledge and my potential to be a danger to patients? I could not believe the words he was saying. We had a roundabout discussion where I disagreed and such however he suggested that I be promoted, no suspension or any other disciplinary action be taken but I would just need to start my PGY 2 year with ICU and "close monitoring" working one on one with an attending physician for the month of August. I was absolutely frustrated with this and I was looking forward to running my own ward team and hated that I was now "center stage." I did not want to go back so quickly to the ICU as I had just went to the PD and to the ICU attendings to ask what specifically I had done to warrant such a poor evaluation. They naturally dodged these questions and were very passive so I KNEW I had stirred the pot so to speak. However, I agreed that this was "what was best."

Bear with me, almost done. You have to remember this is MAY! I have heard nothing but overall good feedback and now I am hearing that there are concerns and no specific concerns just generalized concerns? So, I am studying for Step 3 (which sucked because I was now in ICU instead of an ambulatory rotation which was planned out in advance) and had to study for step 3 while in ICU. I busted my tail the second time; no kidding. Got there 30 minutes earlier, weaning vents, keeping on top of my intern, working incredibly well with the staff and again; not much interaction with the attendings. Step 3 done, felt pretty good and I was ready to start August. About 3 weeks into august (when I guess the ICU attendings felt it was time for them to fill out my evaluations) again blasted except this time it was MUCH worse. They apparently said in the meeting that I was more like an MS III than a PGY II? So again, I am left completely clueless about what I did wrong even though asking for feedback periodically but with no actual responses or anyone to sit me down along the way to tell me exactly what the hell was happening.

As expected, I get another call to see the PD. Long story short "we have to let you go due to unsatisfactory performance." I was literally shocked. Emotion was high, I was so confused. How could this happen? Why is this happening? How could my year of great evaluations lead to termination in less than 2 months? I have 20 days to appeal. I have a lot of support from colleagues and other liaisons at my disposal. I absolutely believe this is unjustifiable and I intend to appeal this to the fullest extent but while maintaing a very professional attitude and I am continuing to work during the 20 days.

My question is, although I feel I have a strong case, I am going to be appealing to the same committee who wants me gone anyway. I was already told that I should "give an answer soon so your spot can be filled quicker." I just believe this is almost inhumane. To terminate a guy without any reasonable feedback, without any objectivity, without any attempt to address concerns or without any advice about how to improve. I am not delusional and I do believe I do not stand a chance against fighting this; but damn it I am going to. Apparently several people have been fired from the program ( at least 3 in the last year) and they all throw in the towel and resign.

I am fighting because my board scores are excellent, I have a great relationship with my co-residents, I think my patient appreciate how I take time to speak with them each day and overall I do not think I have a "fund of knowledge" problem, nor that I am any danger to any patient.

I guess my question is, what now everybody? I am knee deep in this storm of S*&T but I want to be heard and I want those same people who dismissed me to face me. I am not pursuing legal action, I am not going to be disrespectful. I am going to be very professional and although I have been advised by several people about what to do; my case is very different and I am hearing so many different things its making my head spin. Please take the time to read this ramble and let me know what you guys would do. Thanks and I hope that I can make it through this.

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[BlondeDocteur]

I am sorry to hear about your troubles. Firstly it seems that your program went through the legal channels needed to terminate you-- they put you on a formal period of remediation (the second ICU rotation) and then expressed that you didn't complete it satisfactorily. In addition, it seems like you had multiple rotations before May where you were told that the faculty had reservations about your fund of knowledge and medical decision-making. They will be able to point to these as demonstrating a consistent pattern of underachievement, etc., necessary to terminate you.

What you need to do ASAP is put together a serious, full-stop remediation plan together with your PD. Ask for another shot. Come up with an intensive reading program together (Harrisons, key journal articles, MKSAP, whatever else is specific to internal medicine). Come up with some kind of formal assessment of your medical knowledge, differential diagnoses, decision-making, etc. Hell, audit your ICU admit notes from those two months and study your assessment & plan to see what you can improve.

Above all be HUMBLE. If you go into your PD's office and come across remotely arrogant or adversarial, you will be canned, pure and simple. I noted that when you talked about your performance in the ICU you talked about fluffy ephemera like "getting along well with staff." That's awesome-- we should all strive to get along well with staff-- but it does NOT a good doctor make. Take a good close look at your daily notes and plans, your admit notes, the way you handled an especially critical / crashing patient.

So email him/her today. Request a meeting TOMORROW. Lay out this plan. Emphasize how you love this program, love internal medicine, and will do anything it takes to be brought up to speed. And request intensive, detailed, feedback-- over email and in writing if it's too uncomfortable for faculty to do in person, but preferentially in person-- re: your performance. People don't often like to be critical or give bad news and they might like you personally and not want to 'ream' you. But make them do it. Make them give you specific examples. And each time someone points out an area in which you can improve, thank them genuinely for the feedback and promise to rectify whatever the particular deficiency is.

 

[mpdoc2]

I am sorry to hear about your troubles. Firstly it seems that your program went through the legal channels needed to terminate you-- they put you on a formal period of remediation (the second ICU rotation) and then expressed that you didn't complete it satisfactorily. In addition, it seems like you had multiple rotations before May where you were told that the faculty had reservations about your fund of knowledge and medical decision-making. They will be able to point to these as demonstrating a consistent pattern of underachievement, etc., necessary to terminate you.

What you need to do ASAP is put together a serious, full-stop remediation plan together with your PD. Ask for another shot. Come up with an intensive reading program together (Harrisons, key journal articles, MKSAP, whatever else is specific to internal medicine). Come up with some kind of formal assessment of your medical knowledge, differential diagnoses, decision-making, etc. Hell, audit your ICU admit notes from those two months and study your assessment & plan to see what you can improve.

Above all be HUMBLE. If you go into your PD's office and come across remotely arrogant or adversarial, you will be canned, pure and simple. I noted that when you talked about your performance in the ICU you talked about fluffy ephemera like "getting along well with staff." That's awesome-- we should all strive to get along well with staff-- but it does NOT a good doctor make. Take a good close look at your daily notes and plans, your admit notes, the way you handled an especially critical / crashing patient.

So email him/her today. Request a meeting TOMORROW. Lay out this plan. Emphasize how you love this program, love internal medicine, and will do anything it takes to be brought up to speed. And request intensive, detailed, feedback-- over email and in writing if it's too uncomfortable for faculty to do in person, but preferentially in person-- re: your performance. People don't often like to be critical or give bad news and they might like you personally and not want to 'ream' you. But make them do it. Make them give you specific examples. And each time someone points out an area in which you can improve, thank them genuinely for the feedback and promise to rectify whatever the particular deficiency is.

This is out of the PDs hand. The department has come out against him and there's really zero chance they will change their minds no matter how much he pleads. I would do one of two things:
1. Hire a lawyer

OR (not and)

2. Ask your PD if you can be allowed to leave on good standing, so that you'd have a shot at another residency program and plead with 1 or 2 of the Attendings you got along with to support you in your search to find another program.

 

[johndoe44]

I appreciate both of y'all's input. Blonde doc, I absolutely agree with you on many of the points you made. I don't want you to get me wrong, I do not have poor insight. There are expectations to be met and it was made clear to me that I did not meet those expectations. That being said, the second ICU was not remediation as I was promoted to PGY 2 without any probation or under any understanding that my job hung in the balance. I want to also say that I am an extremely humble guy and I have no vendetta against my program.

My concern is the manner in which I was terminated. Legally or illegally, regardless you should not let an intern go through an entire year to the point of signing his PGY 2 contract and then all of a sudden terminate that person on the basis of "here-say".

In reality, I would love to go to the PD and give him a plan such as you advised; the reality is that I was on the radar and was scrutinized and I doubt that there would be anything I could do at this point.

I just think that my work ethic, dedication to my patients, my consistent improvement in management and willingness to take advice and correct mistakes would be enough but I think now that all this has come to fruition that it's like paddling upstream from the event horizon.

I just never would have believed this would happen to me and now I'm going to have to somehow find another job and somehow keep my dignity. This is a huge blow to a person and I guess I was naive about the realities of residency.

 

[mpdoc2]

I appreciate both of y'all's input. Blonde doc, I absolutely agree with you on many of the points you made. I don't want you to get me wrong, I do not have poor insight. There are expectations to be met and it was made clear to me that I did not meet those expectations. That being said, the second ICU was not remediation as I was promoted to PGY 2 without any probation or under any understanding that my job hung in the balance. I want to also say that I am an extremely humble guy and I have no vendetta against my program.

My concern is the manner in which I was terminated. Legally or illegally, regardless you should not let an intern go through an entire year to the point of signing his PGY 2 contract and then all of a sudden terminate that person on the basis of "here-say".

In reality, I would love to go to the PD and give him a plan such as you advised; the reality is that I was on the radar and was scrutinized and I doubt that there would be anything I could do at this point.

I just think that my work ethic, dedication to my patients, my consistent improvement in management and willingness to take advice and correct mistakes would be enough but I think now that all this has come to fruition that it's like paddling upstream from the event horizon.

I just never would have believed this would happen to me and now I'm going to have to somehow find another job and somehow keep my dignity. This is a huge blow to a person and I guess I was naive about the realities of residency.

Are you an american grad? If so you can still get licensed and find some jobs in underserved areas.

 

[johndoe44]

Well I'm American but went to international school so technically i'm a US citizen with ECFMG certification. Don't know if that's the same as FMG on Visa. I want to continue with residency in anything to be honest; I just am trying to figure out what to do.

If I can somehow keep good report with my PD maybe I can get a residency for 2015 match; I've actually already got my ERAS application up and its almost ready but I just don't know where to go from here. I think my board scores and transcript (high honors) would be good enough to overcome this blemish but I would love to stay in the state I am in. Too much going on at once.

 

[michaelrack]

Well I'm American but went to international school ..

you are an IMG

 

[rokshana]

i thought you had to be on probation to be terminated? isn't that an ACGME requirement?

 

[BlondeDocteur]

Residency hiring & firing is pretty much solely the purview of the program director. Unless there is some kind of serious legal or ethical concern putting the department or hospital at risk no one else really cares.

You have nothing to lose. Don't wallow in self-pity-- go into their office tomorrow and try to salvage your job.

 

[johndoe44]

I will try Blonde Doc but I just hate being in this situation. This seriously sucks. I am trying not to wallow in self-pity but its just that "out of your control" feeling that drives me crazy. I've always been in control of what happens to me but this is a surreal feeling. I keep thinking its some ****ty dream that I will wake up from.

However, I do appreciate all the input from everybody. Ya'll are awesome.

 

[johndoe44]

i thought you had to be on probation to be terminated? isn't that an ACGME requirement?

And about probation, the ACGME only requires that a program have a system in place for evaluating residents in a standardized fashion. However, if you look at the termination paper on the contract, they word it were it appears you are entitled to a probationary period however they ultimately can let you go for any reason as long as they have some sort of reasonable documentation. I think its crap and I should have been told " you need remediation" or " your really bad at XYZ, focus on that for now because your job depends on it."

I guarantee that if I would have seen this coming I probably could have avoided it but I honestly did not think I was at risk for termination; that had honestly never been a spoken possibility. That's why i'm so frustrated. Anyway, yes you should be given some sort of official "probation" however its not a prerequisite for termination.

I might just find a PGY 2 spot in psych, PM&R or neuro. I don't know what the hell to do.

 

[Law2Doc]

i thought you had to be on probation to be terminated? isn't that an ACGME requirement?

They told him he was being promoted subject to "close monitoring" in his next ICU rotation. I'm not sure that wouldn't qualify. But as mentioned, it's a one year contract and they can always fire you "for cause" subject to an administrative hearing/appeals process.

My biggest caution to OP is that although they have been resistant to tell you why they don't feel you are up to snuff, that doesn't always mean they aren't sitting on a file full of specific instances where you deviated from expectations. You have to be a little careful here because sometimes it's easier to find your next job without them specifically having to fire you for cause. If you have any attendings you consider allies/friends, it might pay to sit down with them. They won't be able to fix things, but it sounds like you need some general career advice from someone who knows you and the situation.

 

[johndoe44]

They told him he was being promoted subject to "close monitoring" in his next ICU rotation. I'm not sure that wouldn't qualify. But as mentioned, it's a one year contract and they can always fire you "for cause" subject to an administrative hearing/appeals process.

My biggest caution to OP is that although they have been resistant to tell you why they don't feel you are up to snuff, that doesn't always mean they aren't sitting on a file full of specific instances where you deviated from expectations. You have to be a little careful here because sometimes it's easier to find your next job without them specifically having to fire you for cause. If you have any attendings you consider allies/friends, it might pay to sit down with them. They won't be able to fix things, but it sounds like you need some general career advice from someone who knows you and the situation.

L2d

I have been speaking to confidential attendings in the program and I have been trying to get some advise.

I think you also bring up a good point, it would definitely be easier to just resign. But why is that always the case? I have been reading other threads and it seems that a recurrent theme is " go peacefully" however in my mind whether you resign or get terminated, I will still need to explain myself to any program about what happened.

I have the right to an appeal. So, I am going to use that right and make an appeal. At the end of the day, I was evaluated poorly in one rotation and by some of the same people in the span of two months. Not once did they alert me or take the time to tell me what I needed to address. It's like getting a speeding ticket before getting pulled over. They may have " information they are holding" although I highly doubt it or otherwise it would have been brought to my attention. Although they have been busy firing 3 other of my colleagues over the last 14 months so maybe they were too consumed with them at the time.

 

[ThoracicGuy]

L2d

I have been speaking to confidential attendings in the program and I have been trying to get some advise.

I think you also bring up a good point, it would definitely be easier to just resign. But why is that always the case? I have been reading other threads and it seems that a recurrent theme is " go peacefully" however in my mind whether you resign or get terminated, I will still need to explain myself to any program about what happened.

I have the right to an appeal. So, I am going to use that right and make an appeal. At the end of the day, I was evaluated poorly in one rotation and by some of the same people in the span of two months. Not once did they alert me or take the time to tell me what I needed to address. It's like getting a speeding ticket before getting pulled over. They may have " information they are holding" although I highly doubt it or otherwise it would have been brought to my attention. Although they have been busy firing 3 other of my colleagues over the last 14 months so maybe they were too consumed with them at the time.

The idea of resigning is that you can try and negotiate a neutral letter from your PD that can help you to get another residency slot in IM or a slot in another field. By fighting it, you're unlikely to be able to get that. A resignation can look better on applications compared to a termination. You are at a program that has had 3 other firings in the last 14 months. How successful do you truly think you'll be as the fourth one to be able to get it reversed? My recommendation: Negotiate your exit with as good of a letter as you can get and hopefully be able to keep out any particularly vicious comments from future job opportunities. You're in a bad spot, but fighting this is unlikely to really work.

 

[mercaptovizadeh]

The idea of resigning is that you can try and negotiate a neutral letter from your PD that can help you to get another residency slot in IM or a slot in another field. By fighting it, you're unlikely to be able to get that. A resignation can look better on applications compared to a termination. You are at a program that has had 3 other firings in the last 14 months. How successful do you truly think you'll be as the fourth one to be able to get it reversed? My recommendation: Negotiate your exit with as good of a letter as you can get and hopefully be able to keep out any particularly vicious comments from future job opportunities. You're in a bad spot, but fighting this is unlikely to really work.

Yeah, 3 going on 4 firings in a year screams malignant program. Best bet is to try to get that neutral letter, resign, and switch to another specialty (IM may be a possibility, but is probably going to be harder than an unrelated field).

 

[da8s0859q]

Yeah, 3 going on 4 firings in a year screams malignant program.

My feeling as well. OP, what's the deal? Any other issues with whatever program we're talking about? History with the ACGME? What's the resident staff like -- IMG/FMG heavy, anyone else scared of the administration, etc?

Either way, sorry you're in this position. Lot of good advice above.

 

[johndoe44]

I agree with you both, the last 3 resigned and never tried to appeal. If I do this I will be the first ever to attempt to appeal. There is also the CIO who I am speaking with too and looks like this May get dragged out.

Too late now

 

[johndoe44]

My feeling as well. OP, what's the deal? Any other issues with whatever program we're talking about? History with the ACGME? What's the resident staff like -- IMG/FMG heavy, anyone else scared of the administration, etc?

Either way, sorry you're in this position. Lot of good advice above.

I agree. You guys have all been amazing and I appreciate the guidance. I really do.

Can't talk much about the program, sorry just cannot divulge any info but vaguely it's a balanced program in that regard.

 

[BlondeDocteur]

The general wisdom is that resigning a program >>>> being fired in terms of how it appears on your future applications and your chance of getting hired/matched somewhere in the future. Also again the neutral letter from your PD versus a scathing one.

If you can't put together some kind of salvage plan then yes, resign. Did you go to your PD today?

 

[mercaptovizadeh]

I agree. You guys have all been amazing and I appreciate the guidance. I really do.

Can't talk much about the program, sorry just cannot divulge any info but vaguely it's a balanced program in that regard.

Can you contact the other three people who resigned and ask them why they didnt fight it and what their PD LOR was like? They are also best able to advise you on how to transition to a different program.

 

[shopsteward]

You need advice in person from someone who will be on your side. Union rep? Chief Resident? Attendings? Be careful with HR, they are on the employer's side. If you have welfare officers they could help you with your feelings of frustration (which you must not on any account express to anyone in your program), as long as you trust their confidentiality. If you can find a lawyer quickly enough who is expert in these matters, you don't need to let your program know that you have a lawyer if that would tell against you, but can take advice to follow yourself. Now, apart from getting other knowledgeable people on your side, and finding a safe haven for venting your feelings, there are things you need to do.

The first is to read your contract of employment very very carefully. You have two ways of fighting what is happening to you, one is procedural and the other is substantive. Fighting on the procedure is often the easiest, because there is less room for argument. So look at your contract, check the procedures the program should have followed, and put down your arguments for contesting each procedural error you can think of.

For instance, you say you were promoted from PGY1 to PGY2 with no disciplinary action taken, so the first thing you need to do is make sure you have a copy of any record that shows that you completed PGY1 satisfactorily and on time. This will probably be Exhibit 1 in your defence. Your argument is that this document demonstrates that whatever committee and PD "discussions" took place, they were wholly resolved in your favour and that you started PGY2 with a clean slate.

You then need to make as good a record as you can of what happened in your PGY2 ICU rotation. Write down what you did, who you did it with, what skills and knowledge you learnt, what feedback you got, times and people you asked for feedback and didn't get it. If you can, get whatever backup documentation you can to show the accuracy of your record. Try to think of anyone you dealt with on that rotation who might speak up for you. The purpose of this record is to show that as far as you were concerned, everything was proceeding as normal in this rotation, with no evidence at the time to show you failed the rotation. Your argument is that critical evaluations coming several weeks after your rotation ended, with no prior warnings, no factual evidence or specific instances provided to back them up, and no opportunity to remediate during the rotation do not meet the procedural standards required for termination.

To protect your immediate position, what you could do is go to the PD, say you need to protect your position as best you can and at the moment it looks as though you will want to put in an appeal, that you have 20 days in which to do so, that you will need to take that time, and that in the meantime you are proposing to continue working your current rotation to the best of your ability. [cont..]

 

[shopsteward]

You need to think carefully about whether you try to fight on substance as well as procedure. The problem with that is that you are fighting the professional judgement of people who are more qualified than you, and who are much more invested in their medical opinion than in their knowledge of proper employment procedures. Also, fighting on substance can look like a failure of insight. What you could say to your PD is: I'm unhappy with the way the procedures have been applied. I want to learn and improve, and because of failures in procedures I don't have the information I should have which would enable me to do that. If you can help me to understand the specific problems that I am said to have, I am sure I can put in the work I need to correct them.

You also need to ace your current and next rotation. Talk to whoever will be evaluating you, ask for their feedback and make sure it's good or that you remedy anything which isn't.

Good luck.

 

[deleted480308]

I would agree that in most cases an attitude of, "can you please help little ol' me figure out what you want....you're so smart and I'm not and I'll do whatever it is if you need if you'll have mercy" will get you farther than a "lawyer up" attitude......it's not a hard and fast rule, which is why we have lawyers but your choice in tactics here is very important

 

[NotAProgDirector]

You've received a bunch of good advice on this thread.

It is common for interns to start to struggle the last 3 months of the year. This is the time when we want them to be taking charge, developing plans, demonstrating that they can work with indirect supervision. So it's not completely surprising to me that you could have good performance for 8-9 months, and then start to get poor evaluations.

The difficult thing with trying to give you advice is that honestly, I don't know what the problem is. One possibility is that your clinical skills are just fine, and you've been railroaded by a corrupt system. Perhaps you pissed someone off. Or maybe they just pick people to pick on. But in this scenario, you are fine and are getting screwed by your program. That's one option.

The other possibility is that your clinical skills are far behind your peers. In this case, your insight (which you state is fine) is actually not good. Which is not an uncommon problem -- as you can imagine, residents with poor clinical skills and poor insight always blame someone else for their problems. In this case, the problem is you, and you can't see it.

In reality, this is a spectrum -- and you fall somewhere along it. And I can't tell where.

But I'm concerned that your insight isn't as good as you think it is. For example, in your PGY-1 you were pulled into your PD's office and told that your performance on ICU and other rotations was concerning and there were concerns about patient safety. Let later you mention that you had no idea your job was in jeopardy. It is quite possibly true that your PD didn't say "If this doesn't get better, you will be fired", but I think most residents would recognize the seriousness of the situation. From your description, it sounds like you didn't really believe it / take it seriously, just "showed up 30 minutes earlier".

As an IMG who is failing out of a program, I think you also underestimate how difficult it will be to get another position. As has been mentioned on this thread, one thing that can be very helpful is a letter from your current PD supporting you for "another chance". Without that, you may find your options somewhat limited. I am assuming that you were planning on listing this training on your ERAS application. What exactly were you planning on listing for "Reason left?"

 

[dpmd]

I have the right to an appeal. So, I am going to use that right and make an appeal. At the end of the day, I was evaluated poorly in one rotation and by some of the same people in the span of two months. Not once did they alert me or take the time to tell me what I needed to address. It's like getting a speeding ticket before getting pulled over. They may have " information they are holding" although I highly doubt it or otherwise it would have been brought to my attention. Although they have been busy firing 3 other of my colleagues over the last 14 months so maybe they were too consumed with them at the time.

You stated in your OP that
"The comments after each evaluation would normally say mostly positive things but there occasionally were concerns about "needs to continue to improve fund of knowledge" and " needs to continue to read and improve" and " differential diagnosis skills improving."
so it isn't like you never got any warning or indication of what you needed to address. The fact that you were put back into the ICU "under close scrutiny" should also have tipped you off that your job was on the line especially since there were concerns about patient safety due to your care. I find it much more possible that you got acceptable evals earlier in the year because you tried hard and people thought you would improve, but ultimately didn't rather than that the ICU folks are just out to get you. The fact that you refuse to believe that is probably why you failed the rotation again and why your PD really has no reason to retain you. You really need to think back on your decision making and plans you put in place for patients. Did they often need to be changed, did patients have bad outcomes, did you often need to be told what to do for the patient? This is not kindergarten where you get points for being friendly and trying hard. This is a program trying to train competent physicians and they have an obligation to make sure that those that don't meet that standard don't graduate.

 

[johndoe44]

Again, all great advice above. I notice that the last two posts are attending physicians and you both bring up "poor insight" which is interesting considering that insight appears to be what I am lacking. My only question is; how can I GAIN insight if areas of concern are never addressed or brought to my attention?


DPMD, I can definitely see your rationale and that is likely what most people would believe. The unfortunate thing is that I cannot dispute anything that you said because I was never given any information to work with. I don't think anyone is out to get me but I can't rule it out. In my situation, the way everything went down it really didn't appear that I was going to be "under close scrutiny" in the ICU. I mean, if you scrutinize or put anyone in a residency program under the microscope your bound to find mistakes. I honestly don't think I was "tipped" off that my job was on the line. I thought that I was a PGY 2 doing a great job in the ICU and taking care of patient's and was never told otherwise that I wasn't. Call that lack of insight or whatever you want to call it, but to me it feels more like omission of feedback.

However, you guys all know how this is going to end. I will lose my job and whether or not it was warranted is irrelevant. Life isn't fair, I know that for sure. **** happens. I guess I will just take it up the ass and smile and ask for a neutral letter from my PD; which by the way is total bull****. If I do what is highly recommended which is beg for a nice letter and a smile I am just being a coward like everyone else who came before me. Again, I am not mad at pointing out my inadequacies I am mad at the way this was handled. I guess I could use all those stupid phrases people use in times like this to make me feel all warm and fuzzy inside like " everything happens for a reason" or "you'll be a better person for it" or my favorite "God has a plan for you." Truth is, those phrases are all just a bunch of bull**** just like the people who say them.

 

[rokshana]

its not an issue of being a coward….its realizing what you have to do…basically swallow your pride and do what you need to do to be able to save your career…because that IS what you need to do.

I find it interesting that you thought that you were doing a great job in the icu as a PGY-2…yet, its that very rotation that is the straw…so i can see why people are questioning your insight…what make you think you were doing so great?

have you gone back and looked at the pts that you were responsible for? asked an attending you have a good relationship to audit those notes and see what you needed to do differently? is there a senior (or one of the pgy-3 from your intern year) who you can talk to who will tell you the truth about what they heard through the grapevine (and trust me, there was and is stuff on that grapevine…) about you.

did you do as blonde docteur suggested and have a sit down with your PD?

at this point you may very well be right….you may be done at this program, but you need to find out, really find out, what the issues were…so you don't repeat your mistakes at the next program if you get that chance...

 

[MDesquire]

JohnDoe44, Please take what I am about to tell you in the best possible light.

You are completely correct about the prejudicial effect of heightened scrutiny on performance. Its significantly more prejudicial than it is probative. Right now you are trying to rationalize and figure out what you could have done. You are an IMG and a protected class per se. Have you noticed any prejudicial actions taken toward IMGs by your admin? Are you aware of the current trends right now in US medicine that are railroading IMGs and their respective access to training in US hospitals? I'm not attempting to stir up wild conspiracy theories, but you cannot rule out some ulterior motive that might be administrative in nature. It happens more often than you think. You sound introspective, remorseful, humble, apologetic--all the qualities that show great character and a good physician profile. Unfortunately, they are what the 'dark side' counts on in executing their policies whether rationally based or not.

The appeals process that you are going through is purely an administrative formality. Consult with an attorney ASAP, and contact your local Bar Administration to find the right attorney--preferably someone trained in administrative law with academic admin specialization. You need not disclose that you've procured an attorney. To dispel a misconception that has been liberally defined supra, one who 'lawyers up' is often the party that has committed a tort or crime and is on the defensive. That wouldn't be you in the situation. You haven't been accused of breaking the law. You've been accused of incompetence. And you may not have to assume the label of 'victim' either. I would consider yourself a 'prospective plaintiff.' All semantics aside, your primary concern is that letter from your PD that will be extremely critical to your next carrier. You must secure a neutral at worse letter from your PD to protect your future. A negative letter could be damming.

Your insight to 'go peacefully' is intelligent. Keep a low profile. Show good character by making those last days the best possible with a good attitude. And get yourself out of the spotlight, and let a good attorney get things in motion behind the scenes, and prepare to move on. Let your attorney intervene once you are no longer there--either due to extended personal leave or otherwise-- and broker an agreement. Let him be perceived as the thorn in their side and not you. That's what you are paying him to do. She has a duty to uphold the law as much as she has a duty to protect your personal interests.

A few points to consider. The american justice system is predicated on due process and Constitutional rights. Internal tribunals such as this 'appeal' DO NOT respect that fundamental procedure. There is no physician or student "bill of rights" as we have come to understand it. There have been many legislative initiatives to create such rights and determine a more randomized double blind approach to peer review, but nothing has yet taken hold. You will not have the ability to confront your accusers which is critical if you are to truly be judged fairly. That will not happen unless you shift the venue to a proper legal forum. Hiring counsel could arrest that 20 day timeline and buy you more time to negotiate. Once that 20 days is up and the termination is final, it will be much, much more difficult to maneuver.

Possible best case scenario? Your PD is stipulated to providing a neutral letter on your behalf, you walk away, and begin elsewhere. When I say stipulated, I don't mean you trust him with personal assurances. I mean you have him stipulate to a legal binding agreement that exposes him to liability if he chooses to sink you. I know what you're thinking, sounds indignant. That unfortunately is how business often gets done in administrative settings, and I should hope you are not so naive as to believe otherwise. You are being labeled by their admin as incompetent. They have good reason to sink you--but not for reasons you might suspect. They are asserting essentially that you are not fit to continue in your current capacity. By succeeding with another carrier you necessarily, de facto, prove them wrong. That makes them look extremely bad in the court of public opinion, and necessarily casts doubt as to their motive. They don't want you to succeed, because ultimately your success will come back to haunt them one way or another. They will have lost a colleague and necessarily gained an adversary. Karma has no timeline. If you are being terminated without cause, you have remedies, but you must think about making a living 1 or 2 months from now and not 2-3 years when your recovery may be realized.

I've read through dozens of case law on the topics of peer review and wrongful termination. These days following compliance protocols may be as important if not more important that rendering effective care. Advice to review your admitting logs could evidence something. But that can be acted upon much later, one to two years later if indeed it surfaces that there were ulterior motives (money/retaliation) involved. These truths will eventually surface either due to repetitive wrongful terminations or a whistleblower.

I will add, though, that once you pull a physician out of his castle, and they take the stand, they are hardly recognizable. Its a humbling experience when their attorney schools them on the law and how while they thought they were exercising their authority according to their professional scruples in order to decide your fate, as a matter of law there may have been conflicts of interest, retaliation, bad faith, administrative negligence, etc. Just to reiterate, I'm not suggesting you get an attorney to go on the offensive in this situation, but rather to broker a neutral letter and stipulation that should they be called upon by prospective carriers to comment on your departure in the future that they must adhere to a narrow scope of commentary that you stipulate to.

Contact your local Bar Association. Remain anonymous. Explain your situation. Request Attorneys that offer free consultations. Chose one that you feel comfortable with and can accommodate your budget. Keep it confidential, and decide based on you best judgment if you need him/her to intervene. Hindsight is 20/20. You may be kicking yourself later for not seeking counsel. You wouldn't be the first. Good luck.

 

[Law2Doc]

JohnDoe44, Please take what I am about to tell you in the best possible light.

You are completely correct about the prejudicial effect of heightened scrutiny on performance. Its significantly more prejudicial than it is probative. Right now you are trying to rationalize and figure out what you could have done. You are an IMG and a protected class per se. Have you noticed any prejudicial actions taken toward IMGs by your admin? Are you aware of the current trends right now in US medicine that are railroading IMGs and their respective access to training in US hospitals? I'm not attempting to stir up wild conspiracy theories, but you cannot rule out some ulterior motive that might be administrative in nature. It happens more often than you think. You sound introspective, remorseful, humble, apologetic--all the qualities that show great character and a good physician profile. Unfortunately, they are what the 'dark side' counts on in executing their policies whether rationally based or not.

The appeals process that you are going through is purely an administrative formality. Consult with an attorney ASAP, and contact your local Bar Administration to find the right attorney--preferably someone trained in administrative law with academic admin specialization. You need not disclose that you've procured an attorney. To dispel a misconception that has been liberally defined supra, one who 'lawyers up' is often the party that has committed a tort or crime and is on the defensive. That wouldn't be you in the situation. You haven't been accused of breaking the law. You've been accused of incompetence. And you may not have to assume the label of 'victim' either. I would consider yourself a 'prospective plaintiff.' All semantics aside, your primary concern is that letter from your PD that will be extremely critical to your next carrier. You must secure a neutral at worse letter from your PD to protect your future. A negative letter could be damming.

Your insight to 'go peacefully' is intelligent. Keep a low profile. Show good character by making those last days the best possible with a good attitude. And get yourself out of the spotlight, and let a good attorney get things in motion behind the scenes, and prepare to move on. Let your attorney intervene once you are no longer there--either due to extended personal leave or otherwise-- and broker an agreement. Let him be perceived as the thorn in their side and not you. That's what you are paying him to do. She has a duty to uphold the law as much as she has a duty to protect your personal interests.

A few points to consider. The american justice system is predicated on due process and Constitutional rights. Internal tribunals such as this 'appeal' DO NOT respect that fundamental procedure. There is no physician or student "bill of rights" as we have come to understand it. There have been many legislative initiatives to create such rights and determine a more randomized double blind approach to peer review, but nothing has yet taken hold. You will not have the ability to confront your accusers which is critical if you are to truly be judged fairly. That will not happen unless you shift the venue to a proper legal forum. Hiring counsel could arrest that 20 day timeline and buy you more time to negotiate. Once that 20 days is up and the termination is final, it will be much, much more difficult to maneuver.

Possible best case scenario? Your PD is stipulated to providing a neutral letter on your behalf, you walk away, and begin elsewhere. When I say stipulated, I don't mean you trust him with personal assurances. I mean you have him stipulate to a legal binding agreement that exposes him to liability if he chooses to sink you. I know what you're thinking, sounds indignant. That unfortunately is how business often gets done in administrative settings, and I should hope you are not so naive as to believe otherwise. You are being labeled by their admin as incompetent. They have good reason to sink you--but not for reasons you might suspect. They are asserting essentially that you are not fit to continue in your current capacity. By succeeding with another carrier you necessarily, de facto, prove them wrong. That makes them look extremely bad in the court of public opinion, and necessarily casts doubt as to their motive. They don't want you to succeed, because ultimately your success will come back to haunt them one way or another. They will have lost a colleague and necessarily gained an adversary. Karma has no timeline. If you are being terminated without cause, you have remedies, but you must think about making a living 1 or 2 months from now and not 2-3 years when your recovery may be realized.

I've read through dozens of case law on the topics of peer review and wrongful termination. These days following compliance protocols may be as important if not more important that rendering effective care. Advice to review your admitting logs could evidence something. But that can be acted upon much later, one to two years later if indeed it surfaces that there were ulterior motives (money/retaliation) involved. These truths will eventually surface either due to repetitive wrongful terminations or a whistleblower.

I will add, though, that once you pull a physician out of his castle, and they take the stand, they are hardly recognizable. Its a humbling experience when their attorney schools them on the law and how while they thought they were exercising their authority according to their professional scruples in order to decide your fate, as a matter of law there may have been conflicts of interest, retaliation, bad faith, administrative negligence, etc. Just to reiterate, I'm not suggesting you get an attorney to go on the offensive in this situation, but rather to broker a neutral letter and stipulation that should they be called upon by prospective carriers to comment on your departure in the future that they must adhere to a narrow scope of commentary that you stipulate to.

Contact your local Bar Association. Remain anonymous. Explain your situation. Request Attorneys that offer free consultations. Chose one that you feel comfortable with and can accommodate your budget. Keep it confidential, and decide based on you best judgment if you need him/her to intervene. Hindsight is 20/20. You may be kicking yourself later for not seeking counsel. You wouldn't be the first. Good luck.

He's not a "protected class per se". He's a US citizen who schooled outside of the US. He's not being discriminated against based on race, gender, nationality or sexual orientation that he's mentioned.

I think you don't appreciate the involvement a Prior PD is going to have in every step along the way. You can't mandate his prior PD being neutral. In fact that's often the kiss of death. The worst thing a potential employer wants to hear is the neutral statement that "we terminated X's contract early in his second year for reasons I can't legally discuss". An employer is going to picture the worst. Sounds no better than a resignation and maybe increases the odds that the PD through his tone and inflexion will hint that issues weren't small. In this career, no future PD is going to hire someone without talking to the prior PD. And. for licensing end credentialing purposes you are going to need things signed and returned timely from this initial residency for the rest of your career. So you need to handle this in a way that doesn't lead to lingering hard feelings. I think there's a time and place for a lawyer, but it's not always the better path here. A lawyer is a very powerful weapon, that you have to think long and hard before you set into motion, because once you activate such a weapon and shoot up a place it's virtually impossible to stick your head into the carnage and say "but no hard feelings". Lawyers work best when you are dealing with someone you will never have to interact with again, and never need something from again. You sue, get your justice and steer clear. So not always the best for a situation where they will have your paperwork come across their desk every time you need to be credentialed or get a phone call every time you apply for another residency.

 

[Law2Doc]

You stated in your OP that
"The comments after each evaluation would normally say mostly positive things but there occasionally were concerns about "needs to continue to improve fund of knowledge" and " needs to continue to read and improve" and " differential diagnosis skills improving."
so it isn't like you never got any warning or indication of what you needed to address. The fact that you were put back into the ICU "under close scrutiny" should also have tipped you off that your job was on the line especially since there were concerns about patient safety due to your care. I find it much more possible that you got acceptable evals earlier in the year because you tried hard and people thought you would improve, but ultimately didn't rather than that the ICU folks are just out to get you. The fact that you refuse to believe that is probably why you failed the rotation again and why your PD really has no reason to retain you. You really need to think back on your decision making and plans you put in place for patients. Did they often need to be changed, did patients have bad outcomes, did you often need to be told what to do for the patient? This is not kindergarten where you get points for being friendly and trying hard. This is a program trying to train competent physicians and they have an obligation to make sure that those that don't meet that standard don't graduate.

Just to be fair to the OP, there's not a resident on this board who never got an evaluation that told them they needed to "continue reading." that's often what attendings write when they don't have something more specifically constructive to write.

 

[TexasPhysician]

Lawyer up

 

[dpmd]

Just to be fair to the OP, there's not a resident on this board who never got an evaluation that told them they needed to "continue reading." that's often what attendings write when they don't have something more specifically constructive to write.

But how many then failed a rotation, got called into the pd's office about it where they were told the attendings thought they were a patient safety risk, and had their schedule rearranged to do the rotation again (whether it was considered a repeat or not).

 

[BlondeDocteur]

I have to admit I have always been curious why the "resign before you're fired" trick works, in the eyes of program directors. Perhaps @aProgDirector could comment? If you see someone who 'resigned,' say, 10 months into internship, and is applying in the same field or a closely allied one, wouldn't it be very obvious what happened?

 

[TexasPhysician]

I have to admit I have always been curious why the "resign before you're fired" trick works, in the eyes of program directors. Perhaps @aProgDirector could comment? If you see someone who 'resigned,' say, 10 months into internship, and is applying in the same field or a closely allied one, wouldn't it be very obvious what happened?

I think it's mainly a tactic used by some PD's to get residents out without them fighting/appealing. If you resign, you voluntarily give up your rights as a resident right? Either way, the resident is up a creek, but the PD will argue that "resigning" looks better and puts on pressure. This is just my theory.

 

[MDesquire]

He's not a "protected class per se". He's a US citizen who schooled outside of the US. He's not being discriminated against based on race, gender, nationality or sexual orientation that he's mentioned.

I think you don't appreciate the involvement a Prior PD is going to have in every step along the way. You can't mandate his prior PD being neutral. In fact that's often the kiss of death. The worst thing a potential employer wants to hear is the neutral statement that "we terminated X's contract early in his second year for reasons I can't legally discuss". An employer is going to picture the worst. Sounds no better than a resignation and maybe increases the odds that the PD through his tone and inflexion will hint that issues weren't small. In this career, no future PD is going to hire someone without talking to the prior PD. And. for licensing end credentialing purposes you are going to need things signed and returned timely from this initial residency for the rest of your career. So you need to handle this in a way that doesn't lead to lingering hard feelings. I think there's a time and place for a lawyer, but it's not always the better path here. A lawyer is a very powerful weapon, that you have to think long and hard before you set into motion, because once you activate such a weapon and shoot up a place it's virtually impossible to stick your head into the carnage and say "but no hard feelings". Lawyers work best when you are dealing with someone you will never have to interact with again, and never need something from again. You sue, get your justice and steer clear. So not always the best for a situation where they will have your paperwork come across their desk every time you need to be credentialed or get a phone call every time you apply for another residency.

Its a collateral point, but federally protected classes include far broader categories that the one's you mentioned. At the peril of making any gross assumptions about the OP's race, ethnicity, age, gender, religion, orientation, color, disability, etc... I speak in generalizations. If I had to guess, odds are that the decision is likely more financially/compliance motivated than discriminatory. I think they statistically make up the largest group of 'blindsided' terminations.

"once you activate such a weapon and shoot up a place..." - Your likening an attorney to a rampageous murderer is misguided and a bit overboard. Without taking sides on this issue, I am suggesting that there are administrative duties that are lacking internal controls and enforced solely by outside regulatory bodies and the attorneys that bring them under scrutiny. An attorney can open doors that otherwise would be closed to the OP for forwarding his grievance. An attorney will be able to approach the legal department at the OP's institution, and attempt to mediate the matter quietly and tactfully.

What Law2Doc seems to be implying is that your attorney is going to bombard your carrier and shoot from the hip, and that's not the kind of representation I would recommend. Mediation and arbitration if necessary can be highly effective.

You're suggestion that a stipulated non-disparage agreement would allow a statement such as "we terminated X's contract early in his second year for reasons I can't legally discuss" is unrealistic. The specifics of such an agreement would be narrowly tailored. Topics that fall outside of the narrow scope can simply be replied to far more tactfully that such a response suggests. "I'm sorry but I didn't directly observe the candidate in that regard, so I can't honestly comment". Odds are based on the OP's story that his termination is based largely on hearsay. That's a challenge for the OP, his attorney and the PD to get together on and work out. The OP need be most concerned about only his next carrier. A shining reference from a future PD will be enough to marginalize and cast doubt on a narrowly tailored review by his former PD. In the American legal system we have certain beliefs that persons are continually trying to improve and better themselves, and that is why we have statutes of limitation for evidentiary admissions of prior mistakes or character evidence.

My sympathies to the OP for the betrayal he must be feeling. If he has made it this far as an IMG, I am certain he is not stranger to adversity and difficulty. Don't sit around and do nothing. Write to as many administrators as possible, schedule as many meetings as possible, document everything. Take inventory of all persons who could have been involved with your peer review. Get a hold of the corporate articles and bylaws of your carrier and the human resources department and see if there are any obvious conflicts. Talk to the employees who were recently terminated. Perhaps you may discover trends or similarities. Without violating the HIPAA policies, document as much about your notes and orders as you can. This was corroborated by others in this thread...but document it as if you could present it to an objective future third party w/o jeopardizing the sanctity of the medical record.

Feel free to message me privately if you'd like to discuss any specifics regarding your case. I may be able direct you to a variety of free resources that could be helpful to you. I can put you in touch with physicians who have gone through the experience and were much farther along in their careers. They are forwarding legislation regarding peer review amendments. They could be a tremendous help to your case. Wishing you strength through this adversity.

 

[ThoracicGuy]

Its a collateral point, but federally protected classes include far broader categories that the one's you mentioned. At the peril of making any gross assumptions about the OP's race, ethnicity, age, gender, religion, orientation, color, disability, etc... I speak in generalizations. If I had to guess, odds are that the decision is likely more financially/compliance motivated than discriminatory. I think they statistically make up the largest group of 'blindsided' terminations.

"once you activate such a weapon and shoot up a place..." - Your likening an attorney to a rampageous murderer is misguided and a bit overboard. Without taking sides on this issue, I am suggesting that there are administrative duties that are lacking internal controls and enforced solely by outside regulatory bodies and the attorneys that bring them under scrutiny. An attorney can open doors that otherwise would be closed to the OP for forwarding his grievance. An attorney will be able to approach the legal department at the OP's institution, and attempt to mediate the matter quietly and tactfully.

What Law2Doc seems to be implying is that your attorney is going to bombard your carrier and shoot from the hip, and that's not the kind of representation I would recommend. Mediation and arbitration if necessary can be highly effective.

You're suggestion that a stipulated non-disparage agreement would allow a statement such as "we terminated X's contract early in his second year for reasons I can't legally discuss" is unrealistic. The specifics of such an agreement would be narrowly tailored. Topics that fall outside of the narrow scope can simply be replied to far more tactfully that such a response suggests. "I'm sorry but I didn't directly observe the candidate in that regard, so I can't honestly comment". Odds are based on the OP's story that his termination is based largely on hearsay. That's a challenge for the OP, his attorney and the PD to get together on and work out. The OP need be most concerned about only his next carrier. A shining reference from a future PD will be enough to marginalize and cast doubt on a narrowly tailored review by his former PD. In the American legal system we have certain beliefs that persons are continually trying to improve and better themselves, and that is why we have statutes of limitation for evidentiary admissions of prior mistakes or character evidence.

My sympathies to the OP for the betrayal he must be feeling. If he has made it this far as an IMG, I am certain he is not stranger to adversity and difficulty. Don't sit around and do nothing. Write to as many administrators as possible, schedule as many meetings as possible, document everything. Take inventory of all persons who could have been involved with your peer review. Get a hold of the corporate articles and bylaws of your carrier and the human resources department and see if there are any obvious conflicts. Talk to the employees who were recently terminated. Perhaps you may discover trends or similarities. Without violating the HIPAA policies, document as much about your notes and orders as you can. This was corroborated by others in this thread...but document it as if you could present it to an objective future third party w/o jeopardizing the sanctity of the medical record.

Feel free to message me privately if you'd like to discuss any specifics regarding your case. I may be able direct you to a variety of free resources that could be helpful to you. I can put you in touch with physicians who have gone through the experience and were much farther along in their careers. They are forwarding legislation regarding peer review amendments. They could be a tremendous help to your case. Wishing you strength through this adversity.

The gist of what I'm getting from you is that you suggest making alot of waves here. You want meetings with various admins, looking for trends of past firings, and the like. This is not likely to be productive. Each year there are residents that end up getting fired or resign under threat of firing. The number that end up reversing that decision through various hospital committees is negligible. All you are apt to do is annoy the PD and department or worse, make them actively against you and your future goals even away from the program. Negotiating a neutral, objective letter that stays clear of vicious comments and allows the OP to find training to be able to have a career is preferable to the PD that will actively sabotage any attempts at licensing, other training programs, or just life in general.

As it is, you haven't even finished medical school, much less gone into residency. I'm not sure that you have the insight into this exact process to be able to make these comments. In fact you are actively pursuing legal action against a Caribbean medical school for not allowing you to transfer there after being expelled from a USMD school. Just sayin...

 

[TexasPhysician]

A neurology resident I know claimed to have been "fired" and used an attorney to help arrange transfer to another program instead. The PD allegedly wanted her out. The academic center supposedly didn't want to fight the case. Both parties agreed that arranging a transfer was acceptable.

This is all 2nd hand info, so who knows how legit it is. If you are being forced out, I don't see how an attorney could hurt an already bad situation.

 

[ThoracicGuy]

A neurology resident I know claimed to have been "fired" and used an attorney to help arrange transfer to another program instead. The PD allegedly wanted her out. The academic center supposedly didn't want to fight the case. Both parties agreed that arranging a transfer was acceptable.

This is all 2nd hand info, so who knows how legit it is. If you are being forced out, I don't see how an attorney could hurt an already bad situation.

I think they can be helpful or harmful depending on how you use them. If you use them to fight to keep your spot and cause alot of grief with the program or the hospital admins, that's unlikely to be good. If they are used to help negotiate your exit and the terms of such, that's probably a reasonable use.

 

[Law2Doc]

A neurology resident I know claimed to have been "fired" and used an attorney to help arrange transfer to another program instead. The PD allegedly wanted her out. The academic center supposedly didn't want to fight the case. Both parties agreed that arranging a transfer was acceptable.

This is all 2nd hand info, so who knows how legit it is. If you are being forced out, I don't see how an attorney could hurt an already bad situation.

Again it can "hurt" because your current PD will forever have involvement in your career, if only for getting credentialing and licensing things signed, if not actually as a reference for future training.

 

[michaelrack]

It is always good to talk to a lawyer. It isn't always good to let others know you are talking to a lawyer.

 

[Law2Doc]

Its a collateral point, but federally protected classes include far broader categories that the one's you mentioned. At the peril of making any gross assumptions about the OP's race, ethnicity, age, gender, religion, orientation, color, disability, etc... I speak in generalizations. If I had to guess, odds are that the decision is likely more financially/compliance motivated than discriminatory. I think they statistically make up the largest group of 'blindsided' terminations.

"once you activate such a weapon and shoot up a place..." - Your likening an attorney to a rampageous murderer is misguided and a bit overboard. Without taking sides on this issue, I am suggesting that there are administrative duties that are lacking internal controls and enforced solely by outside regulatory bodies and the attorneys that bring them under scrutiny. An attorney can open doors that otherwise would be closed to the OP for forwarding his grievance. An attorney will be able to approach the legal department at the OP's institution, and attempt to mediate the matter quietly and tactfully.

What Law2Doc seems to be implying is that your attorney is going to bombard your carrier and shoot from the hip, and that's not the kind of representation I would recommend. Mediation and arbitration if necessary can be highly effective.

You're suggestion that a stipulated non-disparage agreement would allow a statement such as "we terminated X's contract early in his second year for reasons I can't legally discuss" is unrealistic. The specifics of such an agreement would be narrowly tailored. Topics that fall outside of the narrow scope can simply be replied to far more tactfully that such a response suggests. "I'm sorry but I didn't directly observe the candidate in that regard, so I can't honestly comment". Odds are based on the OP's story that his termination is based largely on hearsay. That's a challenge for the OP, his attorney and the PD to get together on and work out. The OP need be most concerned about only his next carrier. A shining reference from a future PD will be enough to marginalize and cast doubt on a narrowly tailored review by his former PD. In the American legal system we have certain beliefs that persons are continually trying to improve and better themselves, and that is why we have statutes of limitation for evidentiary admissions of prior mistakes or character evidence.

My sympathies to the OP for the betrayal he must be feeling. If he has made it this far as an IMG, I am certain he is not stranger to adversity and difficulty. Don't sit around and do nothing. Write to as many administrators as possible, schedule as many meetings as possible, document everything. Take inventory of all persons who could have been involved with your peer review. Get a hold of the corporate articles and bylaws of your carrier and the human resources department and see if there are any obvious conflicts. Talk to the employees who were recently terminated. Perhaps you may discover trends or similarities. Without violating the HIPAA policies, document as much about your notes and orders as you can. This was corroborated by others in this thread...but document it as if you could present it to an objective future third party w/o jeopardizing the sanctity of the medical record.

Feel free to message me privately if you'd like to discuss any specifics regarding your case. I may be able direct you to a variety of free resources that could be helpful to you. I can put you in touch with physicians who have gone through the experience and were much farther along in their careers. They are forwarding legislation regarding peer review amendments. They could be a tremendous help to your case. Wishing you strength through this adversity.

A lot of what you are describing seems to be how you'd like things to work, but not how things play out in real life. The OP isn't a protected class. His PD has no incentive to mediate. There isn't much grounds to try and force his PD to provide a neutral reference -- there isn't much in this story to suggest the PD is acting illegally in not giving this guy another (third) chance. And yes often unleashing your lawyer is much like unleashing a rampaging murderer. We lawyers like to win even if it gets messy, and it's actually quite rare for the opposing party not to have sore feelings. I'm not saying you would never pull this trigger, but I am saying it shouldn't always be your first resort, and "winning" doesn't always get you to the next rung of your career.

 

[Smurfette]

If you get fired from residency, is it reportable to the national provider databank because it is an adverse action? If yes, that is a good reason to "resign" rather than be fired. I assume it depends on the reason someone is fired?

 

[drcrispmd]

Have you talked to senior residents or the ones who were chiefs when you were an intern? Chief residents should know what is going on and if there really were concerns or what those concerns were. Also your senior residents should have some comments too. Also, your evaluations had vague comments. Did they have any kind of scoring system? Do you have copies of these evals? If not they should be on new innovations. Are your copies the same as what is on new innovations? Did you officially get promoted to PGY2? Do you have documentation that you were officially promoted? Signing a contract does not necessarily mean you were promoted. Did you have a semi annual evaluation with your advisor? What was their impression or comments? I know when we had applicants who had left a residency program, the previous PD letter or even a phone call determined their position on the rank list (or decision to DNR them). Any issues with any staff in the hospital? Did you vent to others or in front of medical students? Did you have guests in the call room? Did you miss pages? Did you disappear, not follow up with your patients, forget to order things, not take the attendings advice as orders, not respond to labs/imaging appropriately, ddx way off or not complete enough? Were you constantly on your phone during rounds? Did you carry the same load as other residents? There is a lot more than showing up early, getting along with staff, and morning notes. Like I said, your senior residents usually have insight to which interns are struggling. A lot who are do not realize it.

 

[MDesquire]

The gist of what I'm getting from you is that you suggest making alot of waves here. You want meetings with various admins, looking for trends of past firings, and the like. This is not likely to be productive. Each year there are residents that end up getting fired or resign under threat of firing. The number that end up reversing that decision through various hospital committees is negligible. All you are apt to do is annoy the PD and department or worse, make them actively against you and your future goals even away from the program. Negotiating a neutral, objective letter that stays clear of vicious comments and allows the OP to find training to be able to have a career is preferable to the PD that will actively sabotage any attempts at licensing, other training programs, or just life in general.

As it is, you haven't even finished medical school, much less gone into residency. I'm not sure that you have the insight into this exact process to be able to make these comments. In fact you are actively pursuing legal action against a Caribbean medical school for not allowing you to transfer there after being expelled from a USMD school. Just sayin...

Again, just to clarify OP, I'm saying keep a low profile, seek legal counsel, tactfully schedule appointments to speak with administrators outside of work hours, tactfully review your performance logs and orders without raising any suspicions. You have every right to these materials and appointments if you so desire at this stage. You may not once your appeal has been decided. DO NOT MAKE WAVES. Consider walking away peacefully having ensured that your next carrier will not be negatively influenced by what might or might not be a wrongful termination. And what I'm also saying is document as much as possible so should any admissions be made later on which they almost always inevitably will, you'll have what you need to recover. A statute of limitations for a fraud or other tort that was actively concealed by an administration is waived in most US jurisdictions. It means in all likelihood you'll be able to clear your name eventually. Similar to a convict who is exonerated after DNA evidence vindicates him, you should make every effort to preserve as much documentary evidence as possible, and of course do so tactfully and without rocking the boat.

@ThoracidGuy Firstly what you failed to grasp in my comment was that the immediate collection of documentary and other evidence was never impliedly for the purpose of bringing an accusatory action now or at any time before OP finds a new carrier. At some point in time down the road, however, OP may have redressability. The rest of your commentary makes me think you didn't read my post carefully. There is an old adage...how do you keep a dollar from a surgeon?.... hide it in a journal. All kidding aside, how you got a gist of 'make waves' from my previous post is perplexing. Scheduling meetings with all who have evaluated OP at some point in time to privately ask them if there were any perceived knowledge deficits, and asking them for constructive criticism is totally benign and normative. It makes him look conscientious.

Recall OP Stated, "Apparently, after the committee meeting my PD called me in and said that the ICU people and "others" ( I am not sure who was there) had some concerns about my knowledge and my potential to be a danger to patients?" And OP you're right, that is here-say, also spelled h-e-a-r-s-a-y, an out of court statement used to prove the truth of the matter asserted. Unfortunately, however, for reasons I alluded to in my original post, an internal administrative railroading is no setting for a fair trial. And the laws against hearsay, need not apply. And in this case not only do you not have the ability to confront your accusers, you haven't even the ability to identify them. Thats whats so disconcerting about these peer reviews. And you really need to discover who the "others" that your PD referenced were. Others typically means that the source of the hearsay was either questionable or perhaps even from an improper source. Your attorney will not in all likelihood go on the offensive against your PD or your dept unless he has some really compelling evidence, but rather simply serve to defend you to the best of his ability and represent your interests with a future carrier. Necessarily he/she will have to show some teeth in order to be taken seriously, but that does not imply a threatening posture. Your attorney will invoke his talents to call the credibility of the hearsay into question tactfully without sounding accusatory. That is something an attorney will have a great deal more experience doing from his understanding of case law and laws of evidence.

RE: "I'm not sure that you have the insight into this exact process to be able to make these comments" My qualifications to comment on this matter are based on a formal education in medical jurisprudence and US administrative law, and for having first hand experience with what OP is going through. If you are asserting that the mechanics of the termination are so drastically different for a PGY2 than a medical student, back up your contention with a rational basis. I fail to see the substantive difference. The premise is consistent whether a student, intern, resident or physician. Its a peer review. Its hearsay. Its subjective and it can be retaliatory. It can be biased. It can be negligent. Whatever insight I may be lacking is due to the fact that I am not familiar with the OP or his actual carrier or players involved. I'm more inclined to think that you are attempting to discredit my level of insight on the grounds that I am at an earlier stage of my medical career than you allegedly are, and for obvious reasons that assertion would be presumptuous. Arguably, I am more qualified to provide commentary than you or any other student/physician who has never walked in OPs shoes. And please get your facts straight if you're going to hold me accountable to my other threads. Yes, OP, I was dismissed from a top 25 US Medical School after substantially completing my degree. There were many similarities between our individual circumstances. There is more to that story than I care to disclose here, but suffice to say that in my circumstance restitution was eventually rendered by my alma mater. I have since obtained a law degree and I have a keen sensitivity to wrongful terminations. Yes, I am pursing a remediation against a fraudulent Caribbean institution responsible for revoking a firm offer of admission and illegally retaining my tuition deposit. I don't see the relevance of these tweets thoraxguy with regards to my ability to understand a specific cause and effect in a specific context. I'm just as human as the next guy and I've got a law degree.... 'just sayin'. And I have no intention of subverting this thread that OP has initiated in good faith, in order to disclaim your skepticism about my qualifications to comment. Message me privately if you want to take issue with my ancillary legal actions, or make your point in that specific thread.

@Law2Doc How can you assert that the OP isn't a protected class if he hasn't disclosed his race, gender, age, etc. I admit I made an impulsive and incorrect assumption that he was an immigrant/minority since he attended a foreign medical school, and I have since redacted that comment. You are asserting that I base my opinion on utopic scenarios. That all depends of whether or not the PD believes the commentaries that warranted OPs termination were truly credible. If not, he does have incentive to prevent any redress. If PD believes there was any iota of retaliation, discrimination or otherwise, he won't admit it but he will be very interested in seeing OP on to a new carrier without subjecting his colleagues to any level of scrutiny. RE: "There isn't much grounds to try and force his PD to provide a neutral reference" Not yet there isn't. You can't rule out the possibility that something will emerge. A fresh pair of eyes may be necessary. And maybe you're right about your latter point, "We lawyers like to win even if it gets messy, and it's actually quite rare for the opposing party not to have sore feelings." However, I would add that the odds of it getting messy are substantially less if there is only one lawyer involved. And if OP's attorney can approach the situation in a tactful, and non-confrontational way the possibility that a PD might seek to resolve OPs concerns without hiring counsel has to be entertained.

 

[Law2Doc]

Again, just to clarify OP, I'm saying keep a low profile, seek legal counsel, tactfully schedule appointments to speak with administrators outside of work hours, tactfully review your performance logs and orders without raising any suspicions. You have every right to these materials and appointments if you so desire at this stage. You may not once your appeal has been decided. DO NOT MAKE WAVES. Consider walking away peacefully having ensured that your next carrier will not be negatively influenced by what might or might not be a wrongful termination. And what I'm also saying is document as much as possible so should any admissions be made later on which they almost always inevitably will, you'll have what you need to recover. A statute of limitations for a fraud or other tort that was actively concealed by an administration is waived in most US jurisdictions. It means in all likelihood you'll be able to clear your name eventually. Similar to a convict who is exonerated after DNA evidence vindicates him, you should make every effort to preserve as much documentary evidence as possible, and of course do so tactfully and without rocking the boat.

@ThoracidGuy Firstly what you failed to grasp in my comment was that the immediate collection of documentary and other evidence was never impliedly for the purpose of bringing an accusatory action now or at any time before OP finds a new carrier. At some point in time down the road, however, OP may have redressability. The rest of your commentary makes me think you didn't read my post carefully. There is an old adage...how do you keep a dollar from a surgeon?.... hide it in a journal. All kidding aside, how you got a gist of 'make waves' from my previous post is perplexing. Scheduling meetings with all who have evaluated OP at some point in time to privately ask them if there were any perceived knowledge deficits, and asking them for constructive criticism is totally benign and normative. It makes him look conscientious.

Recall OP Stated, "Apparently, after the committee meeting my PD called me in and said that the ICU people and "others" ( I am not sure who was there) had some concerns about my knowledge and my potential to be a danger to patients?" And OP you're right, that is here-say, also spelled h-e-a-r-s-a-y, an out of court statement used to prove the truth of the matter asserted. Unfortunately, however, for reasons I alluded to in my original post, an internal administrative railroading is no setting for a fair trial. And the laws against hearsay, need not apply. And in this case not only do you not have the ability to confront your accusers, you haven't even the ability to identify them. Thats whats so disconcerting about these peer reviews. And you really need to discover who the "others" that your PD referenced were. Others typically means that the source of the hearsay was either questionable or perhaps even from an improper source. Your attorney will not in all likelihood go on the offensive against your PD or your dept unless he has some really compelling evidence, but rather simply serve to defend you to the best of his ability and represent your interests with a future carrier. Necessarily he/she will have to show some teeth in order to be taken seriously, but that does not imply a threatening posture. Your attorney will invoke his talents to call the credibility of the hearsay into question tactfully without sounding accusatory. That is something an attorney will have a great deal more experience doing from his understanding of case law and laws of evidence.

RE: "I'm not sure that you have the insight into this exact process to be able to make these comments" My qualifications to comment on this matter are based on a formal education in medical jurisprudence and US administrative law, and for having first hand experience with what OP is going through. If you are asserting that the mechanics of the termination are so drastically different for a PGY2 than a medical student, back up your contention with a rational basis. I fail to see the substantive difference. The premise is consistent whether a student, intern, resident or physician. Its a peer review. Its hearsay. Its subjective and it can be retaliatory. It can be biased. It can be negligent. Whatever insight I may be lacking is due to the fact that I am not familiar with the OP or his actual carrier or players involved. I'm more inclined to think that you are attempting to discredit my level of insight on the grounds that I am at an earlier stage of my medical career than you allegedly are, and for obvious reasons that assertion would be presumptuous. Arguably, I am more qualified to provide commentary than you or any other student/physician who has never walked in OPs shoes. And please get your facts straight if you're going to hold me accountable to my other threads. Yes, OP, I was dismissed from a top 25 US Medical School after substantially completing my degree. There were many similarities between our individual circumstances. There is more to that story than I care to disclose here, but suffice to say that in my circumstance restitution was eventually rendered by my alma mater. I have since obtained a law degree and I have a keen sensitivity to wrongful terminations. Yes, I am pursing a remediation against a fraudulent Caribbean institution responsible for revoking a firm offer of admission and illegally retaining my tuition deposit. I don't see the relevance of these tweets thoraxguy with regards to my ability to understand a specific cause and effect in a specific context. I'm just as human as the next guy and I've got a law degree.... 'just sayin'. And I have no intention of subverting this thread that OP has initiated in good faith, in order to disclaim your skepticism about my qualifications to comment. Message me privately if you want to take issue with my ancillary legal actions, or make your point in that specific thread.

@Law2Doc How can you assert that the OP isn't a protected class if he hasn't disclosed his race, gender, age, etc. I admit I made an impulsive and incorrect assumption that he was an immigrant/minority since he attended a foreign medical school, and I have since redacted that comment. You are asserting that I base my opinion on utopic scenarios. That all depends of whether or not the PD believes the commentaries that warranted OPs termination were truly credible. If not, he does have incentive to prevent any redress. If PD believes there was any iota of retaliation, discrimination or otherwise, he won't admit it but he will be very interested in seeing OP on to a new carrier without subjecting his colleagues to any level of scrutiny. RE: "There isn't much grounds to try and force his PD to provide a neutral reference" Not yet there isn't. You can't rule out the possibility that something will emerge. A fresh pair of eyes may be necessary. And maybe you're right about your latter point, "We lawyers like to win even if it gets messy, and it's actually quite rare for the opposing party not to have sore feelings." However, I would add that the odds of it getting messy are substantially less if there is only one lawyer involved. And if OP's attorney can approach the situation in a tactful, and non-confrontational way the possibility that a PD might seek to resolve OPs concerns without hiring counsel has to be entertained.

First, we have no reason to believe this guy is s protected class so until he says he was, the presumption is he's not. Don't try to assume facts not in evidence to create a case when there isn't one - stop making up facts to suit your story. Second, you are assuming that in his investigation the OP is going to find some evidence of wrong doing or inappropriate firing by the PD, and that's going to be your lynchpin in forcing meetings and mediation and negotiations and nondisclosure agreements. So you are being swayed not by the facts actually provided, but by sensitivities stemming from your own personal situation. A fairer reading of the actual posts by the OP, given that this hasnt happenned quickly, that he's been called in by his PD, asked to redo ICU under close scrutiny, and then they decided he still had issues, etc is that maybe he's just not got great insight and is not grasping the things right in front of him. (If you ask a guy to do X better and he says he understands but then does X the same and does Y better is it your fault or his? ) There's really nothing in his story that screams wrongdoing by the PD unless you are coming at it from your own experience of wrongdoing. Third, you continue not to grasp the point thoracicguy and michaelrack made earlier that it's fine to TALK to a lawyer, but once that lawyer starts setting up meetings, trying to get copies of things, trying to pin down people's statements versus hearsay, the game has changed to an adversarial one. Once you bring your lawyer, most PDs are OBLIGATED to call risk management and get their own. It's not optional -- that's just hospital policy everywhere. Totally different than med school issues. Fourth, your experience at the med school level really doesn't translate to the issues at the residency level. You don't really need your med school deans recommendations, good word, or willingness to sign off on things for the rest of your career the same way you do in residency. Its really not the small word of mouth community residency is. So the downside of fighting tooth and nail is just so much greater that a lot of your advice simply needs to be looked at by people actually on that road who know what the next destination is going to need or want to see/hear to give one another chance. Frankly this is often a situation of "win the battle but lose the war".

Look, I am a lawyer and also know intimately how residencies work. There are times when you are being railroaded illegally and a lawyer can absolutely help. I don't know if this is the OPs situation but he certainly hasn't presented it as such. It reads to a lot of us more like a lack of insight. Often, if the situation is one where the resident wasn't great, was given second chances after talking to the PD, and maybe still lacked insight about it (which is the majority of these situations unfortunately) a lawyers involvement can actually make a bad situation worse. You really don't want to focus on the current position and what they could have and should have done differently. Thats spilled milk -- dont cry over it -- It really doesn't even matter if you ultimately were right. That's a closed door. Your total focus needs to be what will help or hurt you to get the NEXT residency. That's the only victory that matters here -- You need to finish a residency to keep your career float. In the end it doesnt really even matter if your original residncy yanked you around and you can prove it. Residencies are members of a small community. PDs all know each other, at least regionally. You are unlikely to get into a new residency without the good, or at least lukewarm word of your current PD. Few residency programs are going to want to hire you without talking to him first. So it's a touchy situation. Requires delicacy, not an arsenal. There isn't one great answer for how to play this, But the absolute wrong way to get a PD on your side is to bring in your Lawyer and make it adversarial, haul him into meetings, maybe try to force him to say/do certain things. You are imagining a world where a lawyer comes in and smoothes things over, but that's rare, and in most cases the very presence of your lawyer is regarded as adversarial -- you are waving your loaded weapon around, and it sets certain things in motion that won't always be helpful to you as you try to get to that next step. So lawyering up is OFTEN the wrong approach if the goal is a constructive working relationship going forward -- and that's really the goal here.

Unlike your situation, the goal isn't to win. The OP doesnt really care if he can prove hes right -- he needs to end up in a residency and finish his training. In the end right and wrong, winning and losing this battle are irrelevant. If the OP takes his licks and moves on that's a whole lot better than not taking any licks but ending his career with just an intern year under his belt.

 

[meerkat111]

In all fairness to the op, there were many times I felt I wish someone would talk to me abt how things are. In my residency, my advisor was part time and so removed from how things are run. I think the programs should keep residents better informed of their fate from the beginning. Esp since we work so many hrs and everyone tells us not to worry

 

[NotAProgDirector]

These "Lawyer vs Lawyer" posts are too long for me to comment upon in any meaningful form. However:

1. MDesquire seems to be assuming that the resident's clinical performance is actually fine, when in fact his performance may be substandard. There's no way for any of us here to know the real truth. And there's no way any lawyer will be able to tell either.

2. If a resident's performance is substandard, then any assessment of them that I write will include that. It would be malpractice of me to do otherwise. Their final documentation should accurately reflect their performance in my program.

3. Any resident is welcome to hire a lawyer. But I don't talk to lawyers. I talk to my residents. Your lawyer is not invited to any meeting we have, and has no right to be there. This is not a court of law. This is a job.

4. It does sound like the OP didn't get good, timely feedback from the ICU. Or, perhaps they did, but it wasn't direct and concrete enough for them to "get it".

5. There have been several comments that the OP is being fired based on "heresay". Presumably the ICU faculty completed evaluations on OP. That isn't heresay. It's an evaluation of their performance by their supervisor.

 

[NotAProgDirector]

I have to admit I have always been curious why the "resign before you're fired" trick works, in the eyes of program directors. Perhaps @aProgDirector could comment? If you see someone who 'resigned,' say, 10 months into internship, and is applying in the same field or a closely allied one, wouldn't it be very obvious what happened?

It may be a benefit for licensing / credentialing forms. Some of these forms specifically ask you if you were terminated, and if you resign you can answer "no". But any other residency program is likely to see it for what it is. But I've seen residents stretch the truth -- say they left for a health reason, or a personal problem, and hope that no one checks.

 

[ThoracicGuy]

These "Lawyer vs Lawyer" posts are too long for me to comment upon in any meaningful form. However:

1. MDesquire seems to be assuming that the resident's clinical performance is actually fine, when in fact his performance may be substandard. There's no way for any of us here to know the real truth. And there's no way any lawyer will be able to tell either.

2. If a resident's performance is substandard, then any assessment of them that I write will include that. It would be malpractice of me to do otherwise. Their final documentation should accurately reflect their performance in my program.

3. Any resident is welcome to hire a lawyer. But I don't talk to lawyers. I talk to my residents. Your lawyer is not invited to any meeting we have, and has no right to be there. This is not a court of law. This is a job.

4. It does sound like the OP didn't get good, timely feedback from the ICU. Or, perhaps they did, but it wasn't direct and concrete enough for them to "get it".

5. There have been several comments that the OP is being fired based on "heresay". Presumably the ICU faculty completed evaluations on OP. That isn't heresay. It's an evaluation of their performance by their supervisor.

For part 2, would your assessment that you write differ depending on if a resident that was being fired/nonrenewed actively fighting the action versus resigning and not stirring up the pot?

As for part 3, I think the best use of the lawyer is for the resident to discuss how and what to say to best end the situation in as good of a way as possible.

 

[dpmd]

It may be a benefit for licensing / credentialing forms. Some of these forms specifically ask you if you were terminated, and if you resign you can answer "no". But any other residency program is likely to see it for what it is. But I've seen residents stretch the truth -- say they left for a health reason, or a personal problem, and hope that no one checks.

All the forms I have seen ask if you were terminated or resigned to avoid termination so technically you woukd be lying on the form if you said no.