Non residency options

[ThoracicGuy]

Thanks for all the advice. I have not looked into any "accommodations" for residency so I will look into that. But from what some people have been saying it doesnt seem like it is a very promising route to go down in terms of programs allowing that sort of thing.

I dont particularly like talking to people and could maybe put up with a psych or family med residency but it would really be just to get a board certification in a field to use to go do something non clinical related. I would have no interest in that field as a long term career.

As for the concussions they were from sports in college and then a subsequent car accident. Overall just an unfortunate sequence of events but whats done is done. At this point it seems like the most feasible route is going to be looking for a non clinical job with just an MD regardless of the significant "downgrade" from a career standpoint.

I should also mention I have not had to take out any debt for my education so money is not something influencing my decision.

If you choose a field and have no interest in that field, you are setting yourself up for failure.

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[NotAProgDirector]

It would be a pain in the butt for sure, but I think there's always a workaround so that resident gets appropriate experience admitting without staying up all night. Maybe a long call (not overnight) system or a weekend system that could work. Who knows? I think PDs would become creative if faced with this issue. What's the alternative? Would you actually terminate/non-renew an otherwise good/competent resident who was diagnosed with something like bipolar or epilepsy during residency because that person couldn't safely do overnight call? I doubt it.

I think in order to let a resident go for this reason, the program would have to prove that this person is incapable of independent safe practice without overnights. Some of the surgical specialties will likely be able to make that case (neurosurg, for example), but I think it's harder to show that in something like IM because there are workarounds.

It's a complicated issue. I'd like to think that I'd work on finding a solution that was reasonably fair to all involved. The core of the question / issue is whether residency training is "education" = we are teaching you to do a job in the long term, or "employment" = we have a job that we need done, and if you do it you'll learn some skills that will let you do other jobs in the future.

What limits on requests like this would be reasonable? What if someone says that they can only work 6 hour shifts. Or they can only work every other day. Or their medical problem is likely to make them miss one random day per week?

These types of requests also tend to grow with time. What happens if 1/2 of my residents get a letter from their doctor stating that they have insomnia and it would be best if they don't work nights?

I would agree with this. Because so many programs do things differently - and for example in PM&R this is a great example - some programs do overnight call, some don't. So if someone was diagnosed with narcolepsy at the beginning of say pgy2 and they said look i cant do overnight call - when other programs don't do overnight call - i'm sure that would create a legal issue. is it unfair to other residents? Yes. But unfairness as others have pointed out happens - i got royally screwed during most of residency and was denied rotations other residents had, and had to do more an extra month of night float, etc. so crap happens.
I doubt that a program would be like no - it's esential to your pm&r education - when the person could have otherwise completed a program elsewhere with no overnight requirement.

Just because some other program creates a job that the person could do shouldn't force another employer to match. Let's say I create an IM residency that has no nights and no weekends and 40 hour weeks -- nothing stops me from doing this, I could easily meet all the ABIM and ACGME regulations. If I do that, should every other program now have to follow suit if requested?

Using "do I need this skill in order to do my final career" is also problematic. Plenty of residents end up with a career in primary care -- they will ultimately do only phone night call, no ICU, etc. Should all of that be pulled out of their training?

One last interesting example. Let's say you're hiring for a Hospitalist group. You decide to hire a nocturnist. You interview and hire someone. They show up on Day 1, and tell you that due to an ADA medical issue, they cannot work nights. Your group has plenty of people who work only days, or a mix of days and nights. This new employee tells you that they want an accommodation to work only days, and some of the other people can cover nights.

This is a really complicated issue. I'm torn. I want to do the right thing for residents, but also want to be fair to the whole group. I want to be confident in recommending my graduates to work in any aspect of IM. (My understanding is that if you make accommodations for an employee, you cannot mention that in any letter of recommendation. If correct, if someone has night call removed from their schedule, I can't mention it. Similar to time extensions on USMLE exams, it's no longer mentioned on score reports).

 

[Mass Effect]

What limits on requests like this would be reasonable? What if someone says that they can only work 6 hour shifts. Or they can only work every other day. Or their medical problem is likely to make them miss one random day per week?

These types of requests also tend to grow with time. What happens if 1/2 of my residents get a letter from their doctor stating that they have insomnia and it would be best if they don't work nights?

Again, it's about what's required to be a competent internist and not working 24-hour call or nights, I'd argue, doesn't make you incompetent. Working 6-hour shifts likely does, unless you're extending training as there's a huge difference in working 30 hours a week and working 70 hours a week. Half your residents getting a letter for insomnia is a red herring. It's not like accepting one ADA request forces you to accept all.

Using "do I need this skill in order to do my final career" is also problematic. Plenty of residents end up with a career in primary care -- they will ultimately do only phone night call, no ICU, etc. Should all of that be pulled out of their training?

I think that a resident who has an ADA request not to work nights should not be going into those fields and if they do, you have the option of putting that (meaning that they didn't do any nights or 24s) in their letter.

One last interesting example. Let's say you're hiring for a Hospitalist group. You decide to hire a nocturnist. You interview and hire someone. They show up on Day 1, and tell you that due to an ADA medical issue, they cannot work nights. Your group has plenty of people who work only days, or a mix of days and nights. This new employee tells you that they want an accommodation to work only days, and some of the other people can cover nights

That's different because you're specifically hiring a nocturnist. On interview, you should be asking the question - you realize you'll be working nights? They show up on Day 1 and tell you they can't for whatever reason, I think you're well within your legal rights to let them go. You're not required to create a position for them when you were specifically hiring a nocturnist. It's like if Macy's hires someone for their perfume counter and the new hire shows up with a perfume allergy. They're allowed to let that person go. But if Macy's hires someone for the perfume counter who happens to be in a wheelchair and can't reach the perfumes on the top shelf, they shouldn't be fired because they can actually do the job with accommodation.

 

[RangerBob]

Consider taking more time off to allow recovery, so that you could possibly do residency in your choice. There are lots of “cush” prelim/TY programs out there-some of which are in the middle of nowhere and quite competitive.

If you have no debt and really don’t think you’re going to do or ever enjoy clinical medicine, then consider leaving medical school to pursue what you’d really like to do. You don’t sound too excited about the non clinical jobs (not many are).

I can understand wanting to finish something you’ve started, but if your priorities have changed and you’re not in the hole, then move on to whatever phase of life you want. Why delay it, or why chose a second-tier job if there’s something else out there you’d enjoy better (assuming there is something else you’d like to do)?

 

[deleted480308]

Again, it's about what's required to be a competent internist and not working 24-hour call or nights, I'd argue, doesn't make you incompetent. Working 6-hour shifts likely does, unless you're extending training as there's a huge difference in working 30 hours a week and working 70 hours a week. Half your residents getting a letter for insomnia is a red herring. It's not like accepting one ADA request forces you to accept all.



I think that a resident who has an ADA request not to work nights should not be going into those fields and if they do, you have the option of putting that (meaning that they didn't do any nights or 24s) in their letter.



That's different because you're specifically hiring a nocturnist. On interview, you should be asking the question - you realize you'll be working nights? They show up on Day 1 and tell you they can't for whatever reason, I think you're well within your legal rights to let them go. You're not required to create a position for them when you were specifically hiring a nocturnist. It's like if Macy's hires someone for their perfume counter and the new hire shows up with a perfume allergy. They're allowed to let that person go. But if Macy's hires someone for the perfume counter who happens to be in a wheelchair and can't reach the perfumes on the top shelf, they shouldn't be fired because they can actually do the job with accommodation.

But hypothetical residency is specifically hiring someone to work long hours including overnights call, do the job or don’t take the job

 

[Mass Effect]

But hypothetical residency is specifically hiring someone to work long hours including overnights call, do the job or don’t take the job

Actually, they're specifically hiring someone to train to be a competent internist and they can do that without the overnights.

 

[deleted480308]

Actually, they're specifically hiring someone to train to be a competent internist and they can do that without the overnights.

Not if they don’t think they can. Maybe you don’t think it’s needed, so your residents don’t work overnight.

 

[Mass Effect]

Not if they don’t think they can. Maybe you don’t think it’s needed, so your residents don’t work overnight.

But that's the point. That's what I've been saying from the start. The PD would have to make a very compelling case that overnights is necessary to be competent and I doubt that argument will be successful, particularly when you have internists who are doing just fine without overnights.

 

[deleted480308]

But that's the point. That's what I've been saying from the start. The PD would have to make a very compelling case that overnights is necessary to be competent and I doubt that argument will be successful, particularly when you have internists who are doing just fine without overnights.

You also have IM docs who don’t walk in a hospital but you have a hard time trying to say a resident should be allowed to refuse walking in a hospital building. If that residency requires overnights, all residents should be held to overnights

 

[Mass Effect]

You also have IM docs who don’t walk in a hospital but you have a hard time trying to say a resident should be allowed to refuse walking in a hospital building. If that residency requires overnights, all residents should be held to overnights

I meant you have IM residents graduating from residency without working overnight. You don't have IM residents who don't walk into a hospital. Your all or nothing protestation is out of touch with reality.

 

[deleted480308]

I meant you have IM residents graduating from residency without working overnight. You don't have IM residents who don't walk into a hospital. Your all or nothing protestation is out of touch with reality.

Then those applicants can apply there

you are the one pushing all or nothing as you don’t think any PD should be able to do things any way but your way

 

[Mass Effect]

Then those applicants can apply there

you are the one pushing all or nothing as you don’t think any PD should be able to do things any way but your way

Where exactly did I say that? Find it and quote me. You won't be able to because I never said it. What I said was that a PD can't get away with terminating a resident when a legitimate medical issue keeps him/her from doing something like call UNLESS the PD can prove that's a vital part of becoming a competent physician. I fail to see how that's all-or-nothing.

That's the last thing I have to say on this subject.

 

[NotAProgDirector]

But hypothetical residency is specifically hiring someone to work long hours including overnights call, do the job or don’t take the job

Actually, they're specifically hiring someone to train to be a competent internist and they can do that without the overnights.

This, right here, is the issue. If you see residency as primarily an educational issue, then nights are "not necessary". If you see residency as a job that includes nights with a side benefit that you get this great experience that then allows you to go get a better job in the future, then nights are just part of the job even if they have no educational value.

It's not like accepting one ADA request forces you to accept all.

Actually, you do. Once you make a specific accommodation for one person, you're allowing that same accommodation for anyone else with a similar problem. Once you allow someone to do this for what you consider a "good reason", I assure you others will just get a provider to sign a note saying they need it for vague or unspecified reasons -- and once you have a provider note, the employer must abide by that assessment.

I think that a resident who has an ADA request not to work nights should not be going into those fields and if they do, you have the option of putting that (meaning that they didn't do any nights or 24s) in their letter.

My (albeit probably poor) understanding of the law is that I cannot mention this. On ERAS, applicants are asked not if they need an accommodation, but whether they can do the job "with or without reasonable accommodations". That's all you can ask / tell.

That's different because you're specifically hiring a nocturnist. On interview, you should be asking the question - you realize you'll be working nights? They show up on Day 1 and tell you they can't for whatever reason, I think you're well within your legal rights to let them go. You're not required to create a position for them when you were specifically hiring a nocturnist. It's like if Macy's hires someone for their perfume counter and the new hire shows up with a perfume allergy. They're allowed to let that person go. But if Macy's hires someone for the perfume counter who happens to be in a wheelchair and can't reach the perfumes on the top shelf, they shouldn't be fired because they can actually do the job with accommodation.

I see what you're saying, and it comes down to the top quotes. If residency is all about what you need for education, then nights are fully expendable (if you think that what you learn working at night can also be learned during the day). If you see residency as a job that includes nights and days with some education as part of it, then nights are just part of the job.

We have accommodated many ADA requests over the years. I'm just not a fan of removing parts of the schedule / curriculum.

When it comes down to it, I think your argument is better stated as this: Residents should not do nights at all, since it's not really necessary for their education. Residents need more supervision, hence should be working days when supervision is better. Residents shouldnt work nights just because they are low on the totem pole. Hospitals should hire people to work nights, residents should only work nights if there is a clear education reason. In that case, it isn't an ADA issue at all. It could all be moonlighting of some sort.

In the end, I'm becoming increasingly convinced that the simplest solution is differential pay. We would adjust resident salary structure so that you get paid extra for working night shifts. Most likely, the "day pay" rate would go down such that the average resident with the usual schedule would end up with the same pay. Then, residents who don't work nights would just get paid less, and those that cover those shifts would get paid more. But I'm sure someone would say this is unfair to disabled residents, and the headline would be "NaPD discriminates by paying disabled residents less".

 

[deleted480308]

Where exactly did I say that? Find it and quote me. You won't be able to because I never said it. What I said was that a PD can't get away with terminating a resident when a legitimate medical issue keeps him/her from doing something like call UNLESS the PD can prove that's a vital part of becoming a competent physician. I fail to see how that's all-or-nothing.

That's the last thing I have to say on this subject.

@notaprogramdirector responded more eloquently than I have been. I get it, we won’t agree on this