Terminating residents

[fernsa]

Resident Termination is a one of the saddest topics ever. Most of the residents who train to become doctors know nothing else. Many a residency program terminating residents dont bother about what happens to the residents. I've known a good resident who was terminated because of some misunderstanding with his advisor and then placed under a microscope before termination. No one looks good when looked at so closely. Why are residencies ruining lives of these residents. When the residents try to get other jobs or get into other residencies, they are viewed as people who have done something very wrong and are denied their career.
Many times termination can leave a resident jobless, hopeless and despondent.
I am looking for people who feel they have been wrongly terminated from their residencies or who have been terminated for a good reason, but want to make a change.
Is there anyone out there who knows how to help residents who have been terminated from their residency.
Is there anyone who knows of anyone who has been terminated and would like to start a support group.

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[dragonfly99]

Interesting post. I don't know anyone who was terminated, but I know someone who had to repeat 6 months (which I don't think he really needed to do...just got on wrong side of the program director) and I know someone else who basically got booted and/or quit one program and switched to a different specialty at another program and did succeed. However, I agree somewhat with the OP. Not that residents are entitled to finish residency if they do something egregious, but that sometimes a resident becomes targeted for reasons that aren't entirely just, and that the stakes are so high in that once let go from a program, the resident essentialy has a "scarlet letter" label that implies he/she is either incompetent or really evil, when in reality it might have been just a bad fit program, wrong specialty, just tangled with the wrong attending one time, etc. I think if a resident gets booted and has stellar USMLE scores, etc. and has some faculty in his/her corner, the person usually finds another spot. If not, he/she may be up a creek with no paddle...

 

[Hurricane]

I know one resident who was terminated and switched specialties and is now doing very well. My impression is that the termination at the other program involved some personality issues.

However, I know of other residents who were terminated, but only after an extended period in which a clear pattern of incompetence was established, and they were given ample opportunity for help and support. Perhaps other programs terminate more capriciously, but in these cases, it would have been irresponsible for the program to graduate them.

Programs do need to support residents who are struggling, but at some point they need to look out for the patients too, which sometimes means terminating residents who are unable to function as competent doctors.

 

[roja]

Residency termination is a very difficult issue. I have only known one who was terminated. He had been 'remidiated' multiple times. The line was finally drawn when he was caught stealing narcotics from the hospital.

I have known others that SHOULD have been fired. It is VERY difficult to fire a resident. There are those exceptions where it wasn't deserved, but I don't think they are that common. Success can still be had though.

 

[fernsa]

That is really strange that senior members out here have not known many residents who have been terminated.

I know alot of them. And all from one program in family medicine. Over the last 5 years the program has terminated 8 residents. Now the program has itself been terminated from the hospital and not accepting any more residents. The terminated residents have tried to get into other programs, but the PD has refused to give them papers without wanting to intervene. And hence, they were not able to be accepted anywhere else.

There was complaints to the ACGME, but the PD had good documentation that the ACGME could not tamper with accreditation.

Now two of the attendings have resigned because of internal problems; but all the residents believe that the attendings resigned because of bad treatment of residents. We all know that attendings are divided into - Resident friendly attendings and Not Resident friendly. The two who resigned were the only two resident friendly attendings in the program.

Only one of the residents terminated had a drug problem. The others just got on the bad side of their attending and were hunted down and chased out.

Each of them was told that "Every year a resident is picked as a Scape Goat" And that they were the scape goat for that period. And every scape goat was eventually terminated. What does that say about a residency in Family medicine.

Is there any help out there for residents who have faced bad luck like this.

 

[Doni2008]

That is really strange that senior members out here have not known many residents who have been terminated.

I know alot of them. And all from one program in family medicine. Over the last 5 years the program has terminated 8 residents. Now the program has itself been terminated from the hospital and not accepting any more residents. The terminated residents have tried to get into other programs, but the PD has refused to give them papers without wanting to intervene. And hence, they were not able to be accepted anywhere else.

There was complaints to the ACGME, but the PD had good documentation that the ACGME could not tamper with accreditation.

Now two of the attendings have resigned because of internal problems; but all the residents believe that the attendings resigned because of bad treatment of residents. We all know that attendings are divided into - Resident friendly attendings and Not Resident friendly. The two who resigned were the only two resident friendly attendings in the program.

Only one of the residents terminated had a drug problem. The others just got on the bad side of their attending and were hunted down and chased out.

Each of them was told that "Every year a resident is picked as a Scape Goat" And that they were the scape goat for that period. And every scape goat was eventually terminated. What does that say about a residency in Family medicine.

Is there any help out there for residents who have faced bad luck like this.

It's very sad to hear that.

I heard some pyramidal programs, every year they do not renew 1-3 contracts but they often inform residents 4 month before they are terminated.

In contrast, residents in my programs quit intentionally and find another program/specialty. Right now one intern is accepted to another program for PGY 2 position and will move after he finishes 1st year in my program.

 

[fernsa]

Could you tell me which program so that I could relay it some of these guys

Does any one know of any other program that will be understanding to such residents

Thanks

 

[dragonfly99]

Yes I have heard of programs like this (ones where there seems to be 1 or more "targeted"/scapegoat resident each year). The best thing to do in this situation would be to try to get as many good letters of recommendation as you can (i.e. from the "resident friendly" attendings) and try like hell to move on at a different residency. You may have to repeat your PGY1 year though, if you can even get in.

 

[DrMona]

My situation was a little different, but there are some important issues that need to be emphasized. I suddenly found myself in my 4th yr of residency being the target of a PD who never could present to me any specific "charges" against me. The PD could only present some nebulous "perceptions" from an immature new attending (who had only been a resident a few months earlier) about my "lack of confidence" in making clinical decisions. I had volunteered to do an extra 6 months of clinical rotations, so since I had started residency on an off-cycle anyway, I would still graduate at the same time as my resident colleagues.

I then discovered that the PD was trying to change the conditions we had agreed upon -- making my additional 6 months contingent on passing an oral exam that no one else had to complete. The PD was actually trying to kick me out with 6 months left to go in the residency training! I initially left the PD's office very disoriented, feeling "as if I should step in front of a moving truck" to end my misery.

But fortunately I talked with a "resident-friendly" attending supervisor who gave me specific instructions about how to proceed. And I was told that the PD could not base termination on only a very small part of the training that was only based on the PD's perceptions. In other words, the majority of good evaluations trumped the PD's opinion.

The residents facing the prospect of termination should be aware that some PDs try to intimidate the residents so that they will resign on their own. Therefore, they should make certain that all meetings with the PD are documented in writing (preferably with another attending as a witness) and not sign off on anything to which they do not agree.

It would probably be beneficial for the residents to obtain the services of an attorney to assure that due process is followed here. Sometimes when a resident shows up with an attorney, it causes the PD and the department to re-think their proposed plan to terminate the resident. Funny how the fear of litigation can balance the power game taking place?

 

[exPCM]

deleted

 

[docB]

I know alot of them. And all from one program in family medicine. Over the last 5 years the program has terminated 8 residents. Now the program has itself been terminated from the hospital and not accepting any more residents. The terminated residents have tried to get into other programs, but the PD has refused to give them papers without wanting to intervene.

That sounds like a problem with a particular progam. If a program is terminating more than a resident a year that's a red flag to not go there.

It would probably be beneficial for the residents to obtain the services of an attorney to assure that due process is followed here. Sometimes when a resident shows up with an attorney, it causes the PD and the department to re-think their proposed plan to terminate the resident. Funny how the fear of litigation can balance the power game taking place?

I would lay off the bold font a little as it's making your post hard to read.

Remember that showing up at your program with a lawyer is the nuclear option. Hiring a lawyer and getting advice is a reasonable start but once your program knows you have the lawyer they may feel they can't back down If they've got enough dirt and have documented your due process they may feel it's better for them to dump you than to remediate you. Programs have lawyers too.

 

[fernsa]

That sounds interesting.
Well, I think Dr. Chen from the UW 2000 incident should have considered the nuclear option if he knew he had a case. But Some residents firmly believe that they dont have a case.

I know several people who will testify that their attendings told them that they were a scapegoat and several of them who were treated unfairly because of a misunderstanding. At times the program director has favorites and tends to believe everything that she/he hears from them.

To the attending who has written before me. I would say; sometimes one needs to get nuclear. I agree that the PD has a lawyer and thats why they feel invincible. I heard from the GME director that the PD has documented things very well and there usually would be no way around this termination.

I've known someone who had 5 months remaining to go in his residency and they terminated him. They werent able to find dirt on him until the last day of termination when they terminated him with false accusations. And at the time of the dismissal proceedings with the GME director; they didnt even allow him to see his file. This violated Due Process. What if something was written in there that was untrue or was someone else's perception about the truth.

The bottom line is that: If you really believe that you were wronged then GO NUCLEAR before you go balistic.
I believe there should be a class action Lawsuit against all the PDs who think they are invincible or who can target residents and ruin their career.

And whenever there is going to be a bad evalutation for a resident; there should be a lawyer to help the resident. The resident advocate/advisor is usually the one making all the accusations and cannot take on the function of helping the resident. The 'option to have a lawyer' is nonsense as the residents are usually naive and trust their backstabbing advisors or PD. So they must have a (ACGME paid for) lawyer with no ties to the residency.

If anyone wants to help set up a fund and/or a group that would help those residents who have been discriminated for any reason or who have been wronged then contact me at [email protected]
Let us set up a resident grieving forum and spread the news to prevent what happed with Dr. Chen and the itseems nice PD at UW in 2000.
We are doctors, We care First. Let us Care for Our Fellow Doctors also.

 

[razorback58]

http://findarticles.com/p/articles/mi_m1374/is_6_63/ai_110459878/pg_1


Medical education's dirtiest secret - use of medical residents

This is sad but good article about how residents can be terminated.

Yes, the PD does find scapegoats....I have seen it. We lost a guy about a week ago and was terminated without any written warning.
The nurses played a major role in his firing as well.

 

[dragonfly99]

This (resident termination and resident disciplinary procedures) is an important and complex issue. It's not very black and white. I think in many cases there is truth on both side (i.e. that of the resident and that of the PD and/or other administrators). One of the problems is the large power differential between the PD and the resident. Really a resident in these types of situations has no power at all and can only hope the PD is well intentioned. I think bringing a lawyer to a meeting with your program director is truly a "nuclear option" and more likely than not would lead to a resident being fired. Best approach available would be probably to take notes about what was said, make a plan with the PD to do everything he/she wants you to do, and try to document what is being done. Also, "gather the troops" in terms of other attendings who support or like the resident in question, to try and salvage your position because it's very hard to switch residencies if you've been labeled a "problem resident".

I hope everyone will read the Humanist article (posted right above here). That was an extremely interesting article, despite the author's having mixed in the residency work hours issue in with the real topic of the article ("disciplinary psychiatry"). I actually did not know that this practice (forced psychiatric evaluation of students or residents) was common at all, but I do have a friend this happened to. I do think in his case it was more a case of anger of the nurses and fear and retaliation by the program director who kind of had it in for that particular resident. Now the person got labeled with a "personality disorder" which is laughable. He is assertive, extremely smart, and very competent clinically. Personality disordered - NOT! I will say that he probably needed to learn to be less confrontational, but what the PD did in sending him away for several weeks psych eval. and treatment was truly a "nuclear approach" to something that could have been easily dealth with more positively and in a way that wouldn't have had long term negative effects on the resident's career. I will also say that I think that people (i.e. other attendings) know that this goes on, because they will often try to help a resident in this position, or the resident will go on to get a good job or other fellowship, like my friend did. However, not everyone is so lucky.

The other article (about a pathology intern who shot his PD) seems more of a clear-cut case of mental illness and extreme stress in a resident who was misplaced at a particular program. I'm not sure we can avoid all tragedies like this, but I think it does show perhaps how cultural factors come in to play - I think universities have gotten better about providing support for international students (i.e. language classes and mental health services). I'm sure that being an intern in a country foreign to one's own would be extremely stressful. That is understandable. It's clear that shooting someone you are unhappy with (and then yourself) would be considered a maladaptive response in whatever culture one comes from, however. This person was obviously mentally ill.

 

[dragonfly99]

Razorback,
how could they terminate a resident without written warning of any kind? It seems legally risky from the program's point of view.

 

[razorback58]

This resident had done a year of prelim surgery before coming to the family medicine program. He was doing central lines and such and staff at the hospital felt uncomfortable with what he was doing being a first year intern. He was told to "cool it" by the PD. I know he continued to do some things even after the the PD told him to stop.
I was on OB with him when the second thing happened. I was not in the room with the resident but the nurses indicated he was crass and had ask for a vaccum for a delivery. The resident told me he was not serious about the vaccum but the nurse became hypervigilent and the story took on a life of it's own. The nurses stirred up the husband and patient and went to administration. He was called in shortly and was terminated on the spot. The resident denies having any written warnings. I don't know exactly what happened other than he is GONE. The nurses are very happy with themselves and have put a large X on his picture at the nursing station. The PD will not say much other than he was terminated because he was putting patients as risk.

 

[docB]

That sounds interesting.
Well, I think Dr. Chen from the UW 2000 incident should have considered the nuclear option if he knew he had a case. But Some residents firmly believe that they dont have a case.

I’m not familiar with Dr. Chen or with the “UW2000 incident.” If residents don’t believe or don’t know if they have a case that’s when you hire a lawyer to advise you. To clarify I said that the nuclear option is when you take the lawyer to your program. Just getting advice without your program knowing is often just smart.

I know several people who will testify that their attendings told them that they were a scapegoat and several of them who were treated unfairly because of a misunderstanding. At times the program director has favorites and tends to believe everything that she/he hears from them. .

Your use of the word “testify” is interesting. You are really saying that the residents with the complaint say that they were told this. I don’t think that that will be very powerful as it’s a “he said, she said” type of situation and the allegation is coming from the complainant.

To the attending who has written before me. I would say; sometimes one needs to get nuclear. I agree that the PD has a lawyer and thats why they feel invincible. I heard from the GME director that the PD has documented things very well and there usually would be no way around this termination. .

If one has already been terminated by a program they have more reason to go nuclear. In that situation they would likely not even be eligible for remediation so the negotiations would be different. In that situation they would be asking for references or at least to not be torpedoed when looking for another program.

I've known someone who had 5 months remaining to go in his residency and they terminated him. They werent able to find dirt on him until the last day of termination when they terminated him with false accusations. And at the time of the dismissal proceedings with the GME director; they didnt even allow him to see his file. This violated Due Process. What if something was written in there that was untrue or was someone else's perception about the truth. .

Other people’s perceptions of the truth is pretty much always the other side of the story. If not being allowed to see the file violated the contract and the due process system then they might have a case.

The bottom line is that: If you really believe that you were wronged then GO NUCLEAR before you go balistic.
I believe there should be a class action Lawsuit against all the PDs who think they are invincible or who can target residents and ruin their career. .

I don’t even know what to make of that statement. You advocate a class action lawsuit against all PDs who share a certain attitude? I’d be interested to see how you could prove in court that someone has a particular attitude.

And whenever there is going to be a bad evalutation for a resident; there should be a lawyer to help the resident.

You want lawyers to be involved when ever there is a negative eval? That’s just extreme. The idea that every time a resident gets a “needs improvement” comment we all have to lawyer up and go to court is just ridiculous.

The resident advocate/advisor is usually the one making all the accusations and cannot take on the function of helping the resident.

Really? The situations I have seen never involved the resident’s advisor or advocate being the one who was leveling the complaints. They were the ones sticking up for the resident although sometimes there just wasn’t much to defend.

The 'option to have a lawyer' is nonsense as the residents are usually naive and trust their backstabbing advisors or PD. So they must have a (ACGME paid for) lawyer with no ties to the residency. .

I don’t think having some outside funded lawyer to get involved in individual labor disputes is realistic. You’d really do better to push for a standardized due process system with options for arbitration sanctioned by the ACGME. That might be a possibility.

 

[3dtp]

Razorback,
how could they terminate a resident without written warning of any kind? It seems legally risky from the program's point of view.

Perhaps, but at some programs it is done frequently, (or at least less than rarely). This is a topic I know something about. A program terminated two residents quietly the year before I went there, affluent community hospital, prestigious town, etc. The year I arrived, it terminated 5 more. Of these, two were justified.

At least two of the residents were ordered to see a hospital appointed psychiatrist who found "issues." One of the residents was concerned about program mis-information meant to induce residents to rank the program, another about rules violations and a third just complained at the wrong time following a prolonged on-call time (over 40 hours on duty).

One of the residents called me after a final year contract was signed and a week later he was terminated on Christmas Eve. The phone call I got frightened me enough that I insisted this resident come over for dinner. Suffice it to say, that had I not interceded, another UW story would have been repeated.

I worked with these residents, know their stories, know the hospital's side, and know the truth.

In each of these cases, the program's actions were precisely the same. It was though they were reading from the same comic book, only the names of the residents were changed. Four of these residents went on to get into other programs, although it took between 2-4 years to move on. They have all completed their next residencies and are in practice and doing well. I am privy to things that would curl your hair, and lead you to wonder why anyone would ever consider medicine as a career.

A resident at another program in the same system reported to me that "program directors have a meeting where they learn how to 'punish' residents who displease them." [Language tidied.]

Fortunately, I have met with many residency directors at professional meetings, regional medical society meetings and in other forums, who are honest, dedicated and diligent. In discussing these concerns with them, they universally decry such behavior, but when asked if they would work to help remediate such residents, nearly all are at least somewhat reluctant to help residents on the outs with a program. In the words of one PD, "...these guys need to be stopped. They make us all look bad." But, people are afraid that residents with "problems" may actually have problems.

The "nuclear option" is not viable. In many states, the legal protections for residents are non-existent. The courts, the medical boards, feel that "protecting the public" from "bad doctors" trumps the individual. They defer to the program directors and the hospitals who employ them, in all but the most egregious cases. This, coupled with the NRMP match and expectations that once in a program, no matter how bad, no matter how misled one was in selecting a program, you will finish in that program and nowhere else.

This leads to a situation ripe for abuse, human nature being what it is. I agree with above posters who think we need some form of independent, unbiased review with teeth, particularly in light of the ACGME's repeated unwillingness to call abusive programs to task. The ACGME states it will not intercede on behalf of individual residents, the NRMP says it is only a "matching" operation and once the contract is signed, its role is consumated.

This situation was, in part, the basis for the NRMP lawsuit by Paul Jung and company. Not only is the NRMP anti-competitive, it also deprives every single person in residency of a freedom to move from one position to another.

This is not likely to change, as it benefits the hospitals and the government, in that residents are economically and physically restricted from seeking better positions, thus allowing bad programs to continue unabated with little to no incentive to improve. And the powerful will not voluntarily relinquish their power.

 

[dragonfly99]

That is a 10/10 post by 3dtp
I agree 100%. Luckily I never became the target of any PD or administrator in a serious way, but in hindsight I see that it could have happened to me if I had not had luck.

Thanks to 3dtp for helping out those residents. It seems a shame that a resident's career can be ended so easily, though some residents surely do have problems and almost all have some deficiencies. However, that is part of what residency is for - to keep on learning and to learn from one's mistakes and/or deficiencies. 3dtp has pointed out the power imbalance that exists is residencies, and why legal measures/lawyers would generally not be very useful to the resident, why he/she thinks the current situation in residencies won't change any time soon. I agree. This post should serve as a word of warning to med students, interns and residents out there. Medicine is a conservative profession and dissent is generally not tolerated if you are a trainee. Try hard not to run afoul of the wrong person.

 

[fernsa]

Thank you to all who have posted in this forum,

However the question remains. How do we help these resident?

Many a times, the PDs have called the resident into their office and fired them. These residents were so dispondent and wished suicide. This should not happen.

To all the attendings in this forum, I urge you to provide alternatives to these people and help give them hope.

I know of a resident who was terminated and went into major depression for over two years. That resident has since then tried to get into another residency and all attempts have been blocked by the PD who terminated him. The PD refuses to give the resident any documentation, but sends it directly to the program that the resident has applied to. Thus squashing all residency attempts. I know that he was a good resident as I was his superior resident and many times I thought he was very competant and knowledgeble.

So if going through the court of law is not the answer; will any PD or attending step up to the plate and be willing to help?

Please provide residency programs that would step up and help.

 

[nsap102]

Hey, I know this forum is about being fired. I'm not at that point, but I think that I certainly need to have that issue in the back of my mind given my circumstances...

In writing this I thought about keeping it short and simple. But because I am seeking advice, I tried to pack as much info into this as possible...

Here's my situation,

STORY
Halfway through my intern year I rotated with a faculty member, Dr. J, who felt that I would benefit from an additional X months of wards. I, too, felt that I was weak in my ward skills and agreed. These ward months would mean an extension of intern year and hence my residency.

Since then I started to work harder, read more, and work on the problems outlined by Dr. J. However, as the beginning of my extension period neared, I was approached by a senior resident who was adamant that I should not have been retained. His argument was that there were others in the program that were weaker than me. He also felt that I was much a stronger intern than he, himself, was at that point in his residency. In fact a few years earlier he was also asked to be retained, but instead he went to the Chief of the department, the PD and anyone else who would listen to him. The program yielded to his demands and he moved on with the rest of his class as R2. He was successful since then. With that said he urged me to refuse being retained and to move onward.

I thought carefully about what he said. Up until that point I had not really compared myself with anyone else in the program. After all, I was too busy trying to improve myself. A few days later one of my friends in the program, a fellow intern, told me that he knew 100% that my medical knowledge was far greater than his and he remained baffled as to why I had let myself be retained. Along with another friend, it was suggested that one reason that I was retained was because I had not networked efficiently enough - as compared to others in my intern class such as my friend.

With all of the above said, I was galvanized and decided to take the advice of the senior resident mentioned in paragraph 2. Unfortunately for me, the PD that the senior was replaced by is not my current PD "less cool". Either way, things worked out for me some what. The program put forward a new stipulation. I am to do X ward months back to back during which I will get evaluations from faculty attendings. At the end of the X months a committee made up of these attendings will meet and evaluate my performance. If I am ready to go on to be an R2 then the X extra months will count as a part of my second year (hence, I graduate on time with the rest of my class). If, however, my performance is not satisfactory then I am to repeat my intern year. Because I felt confident in my ability, I agreed to the stipulation.

Since then, my X number of ward months has begun. I've already rotated with Dr. J who, albeit reluctantly, agreed that I should progress to an R2 - under close supervision. According to him, I am doing what an R2 should be doing. Interestingly, he said that he didn't want me to feel singled out; or to feel that the program is out to get me. He also mentioned that I am not the only one retained and that there are others in my class who should have been retained but who did not rotate with him, and therefore he could not retain them. (geez thanx for telling me that ). Finally he mentioned that medical knowledge wise I was in the top third of my class, but as a decision maker was in the bottom third. (ok...so I'll work harder!)

However, I ran into difficulty into one of my later ward months. This rotation is with Dr. K. His evaluation bashed the hell out of me in everyway . My medical knowledge is at the level of an intern at best. He also got me on tons of others stuff. Personally, I felt that if I made the same mistake as my senior then I was chastised much more caustically than my senior. In fact there were one or two instances where I got blamed for my seniors mistakes.

SUBJECTIVE THOUGHTS
1. I'm know I'm not God's gift to residency programs. But I also know that I'm not Satan's poison. I do make small mistakes, especially when the team is rounding fast and I may forget to correct an electrolyte abnormality...But I don't feel that I need to repeat my intern year.

2. I honestly feel like I'm under the microscope. It seems that if I make the same mistake that others at my level of experience make, I will be chastised more harshly than my colleague(s). Furthmore, if I make a great decision or diagnoses, nobody gives my any credit...i.e getting a diagnosis and treatment right despite the fact that the attending and/or specialty fellow were on the wrong track. This has happened a few times...

3. Acquaintances in my program look at me differently and feel awkward around me. While I like this program and would gladly continue on here, I do feel that I am "marked" at this program. I am concerned that it's only going to miserable given that faculty who did think highly of me think less and maybe even lesser as time goes on.

4. My evaluations...initially there were average for wards and super for consult months. Since my retention they are all waning. The one by Dr. K made me seem like a ******. I am concerned about my future in this field.

THINGS I WOULD HELP WITH IN DECIDING/DOING
1. Do you have any suggestions?2. Obviously, I've become progressively despondent and withdrawn from my class. Has anyone else in this forum had a similar experience to me? How did it feel? How did you deal with this situation? How do you get over the fact that others may view you as inferior? Are there ideas on how to cope with this? In your case...or in the case of others who are/were in the same situation, what was the final out come?

3. How will retention affect my chances of getting a job after residency? How will it affect my chances of fellowship, should I decide to pursue fellowship?

4. Because I am beginning to feel "marked" it seems that continuing here may prove futile...Has anyone ever transferred out of such a program? What are my options?

5. What about transferring to another specialty? How should I do this? I am obviously concerned that if I apply to another specialty, then once my PD comes to learn about this, he/she will terminate contract. Can you give me any tips on how to proceed with this area?

I would appreciate any good advice.

 

[NotAProgDirector]

This resident had done a year of prelim surgery before coming to the family medicine program. He was doing central lines and such and staff at the hospital felt uncomfortable with what he was doing being a first year intern. He was told to "cool it" by the PD. I know he continued to do some things even after the the PD told him to stop.
I was on OB with him when the second thing happened. I was not in the room with the resident but the nurses indicated he was crass and had ask for a vaccum for a delivery. The resident told me he was not serious about the vaccum but the nurse became hypervigilent and the story took on a life of it's own. The nurses stirred up the husband and patient and went to administration. He was called in shortly and was terminated on the spot. The resident denies having any written warnings. I don't know exactly what happened other than he is GONE. The nurses are very happy with themselves and have put a large X on his picture at the nursing station. The PD will not say much other than he was terminated because he was putting patients as risk.

It sounds like this resident was performing procedures not covered by his residency training (any complications of which would be the responsibility of his faculty). He might be "competent" at central lines given his prio surgical background, but if his current program does not have interns put lines in he shouldn't. Regardless, he was warned, continued this dangerous and franly reckless behavior, and his termination seems reasonable. Of course, I'm guessing at some of this as none of us know the whole story.

 

[NotAProgDirector]

A quick note about "disciplinary psychiatry".

This is completely and absolutely unacceptable. Here's how it should work:

1. Resident X's performance is less than acceptable for whatever reason.
2. I meet with Resident X to review the situation.
3. I become concerned, perhaps, that a psych / drug / EtOH problem may be present.
4. We come to a crossroads -- either the person can continue to work, or they cannot, based upon the problems / concerns.
   • If I decide that the problem is serious enough to warrant immediate removal from work, then a medical evaluation becomes necessary. Resident X cannot return to work until a medical evaluation states that it is safe to do so.
   • If not, then I tell Resident X -- "It is your responsibility to improve your performance. It's my responsibility to help you do so. In that vein, I am concerned that perhaps you have a medical problem that might be interfering with your work. I am your boss, not your physician. As your boss, I am suggesting that you consider getting a medical evaluation. If you would like help setting that up, I am happy to help. If you decide not to get a medical evaluation, and your performance does not improve, a later excuse that 'I had a medical problem that interfered with my performance' will be unacceptable."
5. Regardless of whether the evaluation is mandatory or optional, Resident X is referred to another physician, preferably Occupational Medicine, for an evaluation. The only thing I get from this evaluation is whether Resident X is able to return to work, and with what restrictions. All diagnosis / therapy / followup is confidential and none of my business.

 

[NotAProgDirector]

1. Do you have any suggestions?

2. Obviously, I've become progressively despondent and withdrawn from my class. Has anyone else in this forum had a similar experience to me? How did it feel? How did you deal with this situation? How do you get over the fact that others may view you as inferior? Are there ideas on how to cope with this? In your case...or in the case of others who are/were in the same situation, what was the final out come?

3. How will retention affect my chances of getting a job after residency? How will it affect my chances of fellowship, should I decide to pursue fellowship?

4. Because I am beginning to feel "marked" it seems that continuing here may prove futile...Has anyone ever transferred out of such a program? What are my options?

5. What about transferring to another specialty? How should I do this? I am obviously concerned that if I apply to another specialty, then once my PD comes to learn about this, he/she will terminate contract. Can you give me any tips on how to proceed with this area?

I would appreciate any good advice.

This is a difficult situation that occurs not infrequently. From a PD's standpoint, it looks like this: I have an intern in their 6-9th month. I need to make a decision about whether I am promoting them or not. Their performance is mixed -- not a complete disaster, but some blocks or some evaluations are poor. I am worried that if I promote them to the PGY-2, they will be unable to handle the increased responsibility. If so, then the intern and the students on the team struggle also and it is very bad, not to mention that I now have to rebuild the schedule (which affects everyone else), and either demote or fire the resident. So, what do I do if I think the intern has a 70% chance of success? a 50% chance? A 25% chance? You should be able to see that this is a complex question without an easy answer.

About your situation, a couple of ideas:

1. First, the "do a couple of months, and if things go badly you need to repeat your PGY-1" is a pretty draconian idea. You should complete as many additional PGY-1 months as necessary. Usually I extend people in blocks of 3 months, because it is hard to judge someone on a single block. I demand that the resident being remediated like this get acceptable evaluations from everyone.

2. It is very common to feel horrible about this. You feel like everyone knows (and perhaps they do, if you're in a small program). I can tell you that in my own program, I have had residents in this same position. Some have gone on to become outstanding residents, and really respected by their peers. Those that are successful work hard, read at home, have a mentor, and most importantly are open to feedback.

3. I doubt it will affect your ability to get a job. Competitive fellowships will be near impossible to get. Endo, Neph, etc would still be in reach.

4-5. This is a very common problem. You feel like you are under the microscope, and everything you do is examined carefully. And honestly, you are. Being open to feedback, and asking for feedback on a regular (i.e. daily) basis can help. Transferring programs can help too, but you're certain to need to repeat a large portion of your PGY-1 should you try to do this, and you may find other programs are leery about "taking a risk" with you if you have had trouble in your first program.

Changing fields can be another idea. It's clear that the skill set for IM, Psych, and Path are wildly different. Perhaps your skills are better suited to another field. As long as you could be happy in a new field, it;s worth thinking about. Your PD might not terminate you for looking at another field. It may give them the ability to simply not renew your contract at the end of the year.

Remember that if they extend your PGY-1 for the rest of the year, there is no guarantee that they'll promote you to a PGY-2 at the end.

 

[Samoa]

It sounds like this resident was performing procedures not covered by his residency training (any complications of which would be the responsibility of his faculty). He might be "competent" at central lines given his prio surgical background, but if his current program does not have interns put lines in he shouldn't. Regardless, he was warned, continued this dangerous and franly reckless behavior, and his termination seems reasonable. Of course, I'm guessing at some of this as none of us know the whole story.

That would be like someone who transferred from a surgical specialty to a medical one, continuing to operate. If your faculty (or residents senior to you) can't provide adequate supervision within the scope of their training, you, as a resident, can't do it.

 

[buckley]

SUBJECTIVE THOUGHTS
1. I'm know I'm not God's gift to residency programs. But I also know that I'm not Satan's poison. I do make small mistakes, especially when the team is rounding fast and I may forget to correct an electrolyte abnormality...But I don't feel that I need to repeat my intern year.

2. I honestly feel like I'm under the microscope. It seems that if I make the same mistake that others at my level of experience make, I will be chastised more harshly than my colleague(s). Furthmore, if I make a great decision or diagnoses, nobody gives my any credit...i.e getting a diagnosis and treatment right despite the fact that the attending and/or specialty fellow were on the wrong track. This has happened a few times...

3. Acquaintances in my program look at me differently and feel awkward around me. While I like this program and would gladly continue on here, I do feel that I am "marked" at this program. I am concerned that it's only going to miserable given that faculty who did think highly of me think less and maybe even lesser as time goes on.

4. My evaluations...initially there were average for wards and super for consult months. Since my retention they are all waning. The one by Dr. K made me seem like a ******. I am concerned about my future in this field.

THINGS I WOULD HELP WITH IN DECIDING/DOING
1. Do you have any suggestions?2. Obviously, I've become progressively despondent and withdrawn from my class. Has anyone else in this forum had a similar experience to me? How did it feel? How did you deal with this situation? How do you get over the fact that others may view you as inferior? Are there ideas on how to cope with this?
I would appreciate any good advice.

Hi. I'm a present intern and you seem to be echoing a lot of my sentiments. I do feel some degree of being left-out. But I'm also still leaving the door open that this may very well be a paranoia projection of my own low self-esteem. I try to laugh with everyone, better to laugh with the group, right? But it does hurt. I know if somebody puts me under a microscope (make that a plain cheap magnifying glass), I will be seen with a lot of errors. BUT I will also admit that sometimes I think maybe others are just better at playing the game. Sometimes it's like a stare down contest like who has more self confidence to fight for their views. I'm very nonconfrontational and would rather say sorry than argue. I hate pointing fingers, and I feel that's way more effort than just doing what needs to be done. But your post made me realize that I have to cover my back too. Maybe being the amenable intern isn't always the good path to follow.
As for me, I don't want to switch specialties and I am switching programs. So I really want to get though this...no delays.

 

[buckley]

Oh and don't ever ever think that you are inferior (even if you feel others view you that way.)...If I could re-do my first month, I would take that thought away from my head. It requires a lot of nonchalant self-cheerleading but really, it's a downhill path until I came to realize--wait a minute. I am not inferior. I am not. I'm still struggling to make that uphill climb. What helps me is to back off a bit and say no harm no foul.

 

[Doni2008]

Hi. I'm a present intern and you seem to be echoing a lot of my sentiments. I do feel some degree of being left-out. But I'm also still leaving the door open that this may very well be a paranoia projection of my own low self-esteem. I try to laugh with everyone, better to laugh with the group, right? But it does hurt. I know if somebody puts me under a microscope (make that a plain cheap magnifying glass), I will be seen with a lot of errors. BUT I will also admit that sometimes I think maybe others are just better at playing the game. Sometimes it's like a stare down contest like who has more self confidence to fight for their views. I'm very nonconfrontational and would rather say sorry than argue. I hate pointing fingers, and I feel that's way more effort than just doing what needs to be done. But your post made me realize that I have to cover my back too. Maybe being the amenable intern isn't always the good path to follow.
As for me, I don't want to switch specialties and I am switching programs. So I really want to get though this...no delays.

I also confronted the same situation.

I had some immature, unprofessional attendings. They tried to find something to yell at any residents in crowded places. They want to show off their superiority. Every residents in my programs do not like them. They do not teach us any thing but bring troubles to us.

One attending in my program is a liar (many residents in my program said that). His patient admitted at night, resident paged him 3-5 times but he did not reply, then in the morning he called PD saying that his pt admitted for 2 days but no one informed him. I had one of his pt, I paged him to inform him about the important abnormal labs (CAT of head showed acute infarct), he told me that do not bother him with such results. Then next time, I had another of his pt and I did not inform him about urine C/S result with blebsiella infection sensitive with Gentamycin, he called my PD to complain me not to inform him.

Our fellow residents and me work hard and cover RN, Secretary, and MD job (do blood work, foley, NG, med administer; bring samples to labs; put lab order in computer; prepare ourself equipment for procedures; call radiology/ultrasound to send pt, call admitting service to ask for bed to transfer pt..). We can stand the hard work but dissapoited with the ways they treat us.

If some one yells at you at work but not your mistake/or minimal mistake, you may feel depressed, then confused and then things worse. You may lose you confidence and concentration. You may feel you are out of the program. It happened to me.

I met a 4th year resident. He told me that this happened to everyone in the intern year. He advised me to be supposed to be blind, deaf, and mute in such situation and I will survive as others do.

My best lession for the intern year: be supposed to be blind, deaf, and mute in some situations.

 

[tuscanito]

I also confronted the same situation.

I had some immature, unprofessional attendings. They tried to find something to yell at any residents in crowded places. They want to show off their superiority. Every residents in my programs do not like them. They do not teach us any thing but bring troubles to us.

One attending in my program is a liar (many residents in my program said that). His patient admitted at night, resident paged him 3-5 times but he did not reply, then in the morning he called PD saying that his pt admitted for 2 days but no one informed him. I had one of his pt, I paged him to inform him about the important abnormal labs (CAT of head showed acute infarct), he told me that do not bother him with such results. Then next time, I had another of his pt and I did not inform him about urine C/S result with blebsiella infection sensitive with Gentamycin, he called my PD to complain me not to inform him.

Our fellow residents and me work hard and cover RN, Secretary, and MD job (do blood work, foley, NG, med administer; bring samples to labs; put lab order in computer; prepare ourself equipment for procedures; call radiology/ultrasound to send pt, call admitting service to ask for bed to transfer pt..). We can stand the hard work but dissapoited with the ways they treat us.

If some one yells at you at work but not your mistake/or minimal mistake, you may feel depressed, then confused and then things worse. You may lose you confidence and concentration. You may feel you are out of the program. It happened to me.

I met a 4th year resident. He told me that this happened to everyone in the intern year. He advised me to be supposed to be blind, deaf, and mute in such situation and I will survive as others do.

My best lession for the intern year: be supposed to be blind, deaf, and mute in some situations.

we are human beings...we MUST NOT STAN BLIND, DEAF AND MUTE!!!

THIS GARBAGE MUST END SOON!

I FEEL PAIN KNOWING THAT THERE ARE SOME GOOD RESIDENTS TREATED BAD...

AND I WILL START MY RESIDENCY SOON SO I FEEL SCARED AT THE SAME TIME.

 

[buckley]

i know i have played the blind/deaf/mute card several times, just because i felt i had no other choice but to do so...something along the lines of "resistance is futile"

but i guess i will just add that famous line--know when to blow.

 

[Winged Scapula]

i know i have played the blind/deaf/mute card several times, just because i felt i had no other choice but to do so...something along the lines of "resistance is futile"

but i guess i will just add that famous line--know when to blow.

Well that might help you be more well liked!

 

[c5a]

i am a bit concerned after reading about the disciplinary psychiatry article. in my first week of residency i was on the ward team with an attending who is very strict with the residents. after a week of verbal abusiveness, i had an acute stress episode, and was called in to talk to my PD. he set me up with a psychiatrist, who i saw once, and that was the end of it. i now get along much better with this attending, and the others as well, in my opinion.

but after reading that article, i'm bothered by this. will this be part of my permanent record?

can they hold this on me if, and "pull it out of the box" so to say if they want to?

sometimes i feel like residency can be a very political place. you want to make friends (advocates) as much as possible. there seem to be mini alliances among residents/attendings, and if you're in with the group, you're in, in spite of your errors. but those same errors, committed by someone who does not really fit the "mold" of the program, might be ousted, more for personality differences than for medical decision errors.

i feel like i'm doing well "politically" so to speak, and i think i fit well socially into the program with attendings and residents, but i do make medical mistakes. i feel like this episode my first week is a blackbox label on me, and can be used to my disadvantage if need be.

 

[BlondeDocteur]

I think the "permanent record" is something they threaten you with in elementary school, nothing more.

 

[elizabeth5863]

Wow... this is a depressing thread...
I think I will be reading my books more diligently since I am starting on an off-service rotation.

 

[michaelrack]

I think the "permanent record" is something they threaten you with in elementary school, nothing more.

The "permanent record" definitely exists for doctors.

 

[dragonfly99]

Agree with MichaelRack
If you think that residency program directors don't keep a file on you, you are wrong.
Also, it doesn't end with residency. Hospitals have committees that go over patient cases and charts, and if they decide you are practicing substandard medicine you can get "dinged". Also, a practicing physician (or resident) who is seen as bad-tempered, or just disagrees with the prevailing wisdom at a particular hospital or practice, can be labeled a "disruptive physician", with harm to his/her career. Luckily I have never personally experience this, since I tend to be mild-mannered and dislike conflict, but it's something for everyone to be aware of.

 

[3dtp]

I think the "permanent record" is something they threaten you with in elementary school, nothing more.

Absolutely positively wrong. This "permanent record" will contain things that will astonish you and can and will be used against you should you find yourself on the wrong side of the street. For example, an innocent comment in the resident's lounge, or perhaps a slightly off color joke gets noted and is placed in the "permanent record." You have a bad day and irritate an attending, who complains to the PD. The off color joke and your crankiness get you an RSVP to the PD who comments that you seem tohave a problem with professionalism and evidence of this is pulled out and placed on the table for you to respond to. Never mind there are a hundred positive things in the file. You are in VDS. Make no mistake about it, in residency, anything you say, do not say, think or do not think can and will be taken down in evidence and used against you should the powers that be decide it should be so.

Tread lightly my friend, grow eyes in the back of your head and stay off the radar.

 

[dragonfly99]

3dtp is 100% correct. What you want as a resident is to be VERY friendly to attendings and the chief residents, and become popular. If you cannot do that, then just stay under the radar and you'll be O.K.

 

[eforest]

Eeek! This thread scares me to death. Wouldn't it be in the program's best interest NOT to terminate a resident? This creates more work for others- and does the particular hospital involved see any financial benefit? My understanding is that the resident is funded by an outside source, and when he/she is gone, the hospital doesn't see the money "saved."

Is it really enough to get on an attending's "bad side?"

 

[secretwave101]

I was selected by my PD to serve on the Board that is hearing the appeal of one of our residents that was recently fired. It's horrible. The Board is made up of faculty members and hospital administrators. I'm the token resident.

No matter how I vote regarding the final decision regarding this resident's termination, I'm on the bad side of someone. Irrespective of the case itself, how am I expected to go against the faculty member on the Board? They've already decided this resident needs to go...what if the Board forces the faculty to take him back? What if they have to take back a resident they fired...because the resident voted against us?

As mentioned, residents have no power. This wouldn't be so bad if we didn't need to keep our jobs so desperately (at least, with 4 kids and a quarter mil in loans, I sure do). Me, with no power whatsoever, now have to serve on a Board where I'm caught in a power-differential meat grinder. There's no way to make everyone happy, and there's no way to "fly under the radar". The question isn't whether or not I can escape without pissing someone off...it's who's the least dangerous to cross?

I've got 8 months to go. Just 8 little months. Less time than it takes to gestate a human being. All I want is to make it.

 

[buckley]

You have my prayers. That is not a good situation to be in...

 

[dragonfly99]

secretwave
you shouldn't have been forced into this position.
I don't know what to tell you, except I guess try to vote with what you really think. I mean, if the resident is really bad then maybe he/she needs to go, but perhaps a remediation plan could be worked out. Most likely you are there as a "token resident" as you say. Your PD must think you are a good resident, or you wouldn't have been appointed to that board, so I think you don't have to worry for yourself, personally, whichever way you end up voting.

 

[medicinesux]

I would've simply said, NO. I'm sorry but you can keep me dangling in the hospital extra hours, have me carry yet another patient on my overloaded census, or spring an extra call on me, but that is simply crossing the line. Getting paid a Taco Bell hourly wage is no where near enough to force me to serve on a kangaroo court like that.

 

[NotAProgDirector]

Fair hearing panels like this should have residents on them. The mistake is that you should never be on a panel looking at one of your own residents. Assuming your institution has more than one program, a resident from a different program should be used. In fact, EVERYONE on the fair hearing panel should be from a different program or an administrator not associated with that program.

The problem with fair hearings is that they quickly turn into a "he said - she said" situation. The people on the panel have no direct experience with the resident in question. They hear what the PD has to say, and what the resident has to say. In order to overturn what the PD has decided, there has to be significant evidence of something unfair or capricious at play.

PD: "This resident is dangerous and incompetent, and I have evaluations to prove it"
Res: "My skills are fine, and I have evaluations to prove it"

The fair hearing can really only answer a single question -- was the PD's decision fair? It can't answer the question "Was the PD's decision correct?"

 

[CaMD]

As a soon-to-be resident this thread is TERRIFYING!!

What are the best questions to ask in order to discover if a program has this kind of record? Will current residents feel comfortable answering honestly?

 

[3dtp]

As a soon-to-be resident this thread is TERRIFYING!!

What are the best questions to ask in order to discover if a program has this kind of record? Will current residents feel comfortable answering honestly?

'Tis a nasty business, it is. There are no good ways to directly address this. Some residents are reticent, some have axes to grind. So, the question is, who to believe.

As for objective measures, there are some measures in FREIDA, but this data is self reported and may not be accurate. One measure I've watched is the program completion rate statistic. I think it's still published. If the completion rate isn't 100%, I think it's a fair question to mention it and ask why x residents did not complete the program. It occurs to me you might ask for the names of residents who have completed the program from those in the program. Then call them. You might be able to get a more straightforward scoop from someone who's a year or more out from the program, but again that information is dated. During an interview lunch in a litigation intensive specialty (OB) someone asked if any of the residents had ever been sued. (They had). Then someone else asked if any residents had ever sued the program. The PD turned bright red, and after a moment, answered yes and refused to elaborate further.

 

[yeasterbunny]

What a spectacular/horrifying thread! I had no idea.

As a TY, I think I am not in exactly the same situation as for many of you already in your categorical residencies, but I will certainly think twice about my comments and behavior from here on. I can think of certain residents even in my one year program that I now feel fearful for. They did make it clear to us in our initial orientation that we should not view this as a freebie year, and that they did have the power to keep us from ever seeing our definitive residencies.

I'm worried now that I had to ask my PD to be excused from an in-training exam to be with my wife while labor is being induced next week.

 

[3dtp]

What a spectacular/horrifying thread! I had no idea.

As a TY, I think I am not in exactly the same situation as for many of you already in your categorical residencies, but I will certainly think twice about my comments and behavior from here on. I can think of certain residents even in my one year program that I now feel fearful for. They did make it clear to us in our initial orientation that we should not view this as a freebie year, and that they did have the power to keep us from ever seeing our definitive residencies.

I'm worried now that I had to ask my PD to be excused from an in-training exam to be with my wife while labor is being induced next week.

Good grief! Are you in my TY program?!!!!

 

[yeasterbunny]

Good grief! Are you in my TY program?!!!!

Um, only if by your indicated "midcoast" location you meant midcoast of Lake Michigan.

 

[peerie]

This is a good thread, and one that needs to be brought up. If you are not aware of these potential issues, than you cannot protect yourself and pro-actively watch out for it.

Knowledge and awareness can go along way.