I saw he wrote in other thread that he will be starting residency again soon.
Terminating residents
- Thread starter fernsa
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I saw he wrote in other thread that he will be starting residency again soon.
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Hey everyone,
I managed to do two weeks of an anesthesia rotation at my institution. I realized that clinical medicine and the thought process it entails better suits my skill set. Now, I suppose someone else could answer this question- when it comes to LORS, would I want them all to come from my previous attempt at pathology, or a combination from med school and my program. Would it be a worthwhile endeavor to obtain one from my PD despite that the fact that a strong one cannot be written in my favor? I did address the issue in my personal statement about why I would want to change fields- stating desire to interact with patients, more involvment with management, ect. In addition, I realized that being in a tertiary care center was not the most beneficial environment for me personally, as most of my successfull rotations in med school were completed at medium sized institutions.
I had the GME director at my institution review my PS and application and believes that it is good, considering the circumstances. In addition, I will have a few other physicians review it. In addition, I will be talking to a physician in an academic center to discuss my situation and ask for advice.
I am working on resolving my "issues", as I believe that they played a role in my demise the first time around. I realize that had I dealt with these earlier, it is likely that none of this would have occured.
Now, I guess my questions are, what other sorts of documentation should I get from my first program? And what typically would transpire between two PDs when they talk to each other?
I managed to do two weeks of an anesthesia rotation at my institution. I realized that clinical medicine and the thought process it entails better suits my skill set. Now, I suppose someone else could answer this question- when it comes to LORS, would I want them all to come from my previous attempt at pathology, or a combination from med school and my program. Would it be a worthwhile endeavor to obtain one from my PD despite that the fact that a strong one cannot be written in my favor? I did address the issue in my personal statement about why I would want to change fields- stating desire to interact with patients, more involvment with management, ect. In addition, I realized that being in a tertiary care center was not the most beneficial environment for me personally, as most of my successfull rotations in med school were completed at medium sized institutions.
I had the GME director at my institution review my PS and application and believes that it is good, considering the circumstances. In addition, I will have a few other physicians review it. In addition, I will be talking to a physician in an academic center to discuss my situation and ask for advice.
I am working on resolving my "issues", as I believe that they played a role in my demise the first time around. I realize that had I dealt with these earlier, it is likely that none of this would have occured.
Now, I guess my questions are, what other sorts of documentation should I get from my first program? And what typically would transpire between two PDs when they talk to each other?
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I would say that you want:
LOR #1 - your Path PD. You're not looking for a "stellar" LOR. You're looking for a "this guy/gal is worth a second chance" LOR.
LOR #2+3 -- letters from all clinical rotations you have done. You've mentioned anesthesia, and I think something else recently. Get letters from these.
If given the above you do not have 4 letters, then consider something from your prior medical school training, especially a letter from the IM PD you mention rotating with.
LOR #1 - your Path PD. You're not looking for a "stellar" LOR. You're looking for a "this guy/gal is worth a second chance" LOR.
LOR #2+3 -- letters from all clinical rotations you have done. You've mentioned anesthesia, and I think something else recently. Get letters from these.
If given the above you do not have 4 letters, then consider something from your prior medical school training, especially a letter from the IM PD you mention rotating with.
Hey brother,
just as a total aside, I wanted to congratulate you on taking your issues seriously, and starting to realize the impact they had on you and taking steps to deal with them. I know it can be a hard, abstract process sometimes, especially to even start.
just as a total aside, I wanted to congratulate you on taking your issues seriously, and starting to realize the impact they had on you and taking steps to deal with them. I know it can be a hard, abstract process sometimes, especially to even start.
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I know for a fact that it was a precipitating factor in my demise first go around as it occurred about a month before residency began and affected me greatly. I just wish that I had the foresight earlier to seek help with it before it drastically affected my performance.
I would not be too hard on yourself. The evaluations may be subjective and the motivations of your evaluators may be colored by your personality or your interactions with other attendings or influential people in the program. Medicine requires an appreciation of justice, yet the system, at least in training, is authoritarian. What pharoah says is law, and pharoah can change the law to meet pharoah's need. This concept goes against the American way but is tolerated in medicine because it is still an arcane art to most of society.
You would be surprised that people are graduated who commit blatant malpractice or truly unprofessional conduct that could affect licensure. What they have in their favor is a strong influential advocate within the program. And in your case you have not committed such sins but are deemed to need remediation.
It is hard to make a case without all the facts, but what is known is that attendings communicate with each other. They are a close bunch. If you anger one attending, there is a chance you will anger all of them. The ones that stand for their conscience are not the ones that survive petty office politics. The chief resident could be influenced to give you attendings who are more likely to evaluate harshly. He cannot be blamed for his actions as he will more likely than not be subjected to the undue influence of his superiors. Hell, the program director can even influence your evaluations by selecting for you attendings that are amenable to his suggestions.
You must find in yourself someway to bring these attendings back into your corner. This may require you to feign submissiveness and make your attendings feel that you need them, that they are not wasting their time on you. If you cannot then you will probably need to move to a different program. Residency training is a game onto itself that sometimes has nothing to do with clinical skills, yet it will be in the name of patient care and clinical skills that you will be crucified. If you want to go to the next more independent stage, you will have to put up with its many times malignant personalities. It is a lesson that is not taught in class but learned on the wards.
This is a grave hypocrisy of medicine. In training, you can be crucified for conduct that could possibly result in harm no matter how far fetched or miniscule. Yet once you are graduated, to suffer an adverse malpractice verdict, an attorney must prove the sufficiency of the evidence to permit a finding of the facts, the weight of the evidence as establishing the facts, the existence of a duty, the general standard of conduct, and the particular standard of conduct against you to win.
The current law stands against you the resident in challenging competency issues as it treats you as a student in this situation. However, it is changing. Just recently, the courts have defined residents as employees for the collection of social security taxes. The hospitals had the temerity to claim residents as students to avoid these taxes.
As the cases meander through the courts, this concept of the resident as a student may change as more and more cases are won on the merits in favor of the resident. At stake on the one hand is the presumed competency of graduated residents which could affect patient care, and on the other hand, the capricious injustice that some residents suffer with a contract termination that could end their medical career without a fair and equitable due process procedure. Imagine a world where one day you are accused of a crime/competency issue, judged and sentenced to a year of hard labor/extended training all by the same person. This scenario occurs in a police state not in one ruled by law. There can be no justice without an objective finding of the facts from which fair inferences could be applied to the premises of justice. Unfortunately, the current system allows the usual cherry picking of inferences that favor the dominant side over the subservient.
Quite frankly, the lack of leadership from the ACGME/AMA for residents in your situation represents an issue of moral legitimacy. The federal government may spend about 120k to 600k on a resident's post-graduate training. The resident may have spent 200k for a medical education. To have it ended in such an arbritary fashion multiplied by several hundred cases a year represents a significant waste of public funds and the infliction of anguish many fold.
The wheels of justice roll slowly but they do roll. Whether ACGME/AMA will lead the way is questionable, but it will face a challenge to its authority in the coming generation if it does not act equitably in this recurring fact pattern.
You would be surprised that people are graduated who commit blatant malpractice or truly unprofessional conduct that could affect licensure. What they have in their favor is a strong influential advocate within the program. And in your case you have not committed such sins but are deemed to need remediation.
It is hard to make a case without all the facts, but what is known is that attendings communicate with each other. They are a close bunch. If you anger one attending, there is a chance you will anger all of them. The ones that stand for their conscience are not the ones that survive petty office politics. The chief resident could be influenced to give you attendings who are more likely to evaluate harshly. He cannot be blamed for his actions as he will more likely than not be subjected to the undue influence of his superiors. Hell, the program director can even influence your evaluations by selecting for you attendings that are amenable to his suggestions.
You must find in yourself someway to bring these attendings back into your corner. This may require you to feign submissiveness and make your attendings feel that you need them, that they are not wasting their time on you. If you cannot then you will probably need to move to a different program. Residency training is a game onto itself that sometimes has nothing to do with clinical skills, yet it will be in the name of patient care and clinical skills that you will be crucified. If you want to go to the next more independent stage, you will have to put up with its many times malignant personalities. It is a lesson that is not taught in class but learned on the wards.
This is a grave hypocrisy of medicine. In training, you can be crucified for conduct that could possibly result in harm no matter how far fetched or miniscule. Yet once you are graduated, to suffer an adverse malpractice verdict, an attorney must prove the sufficiency of the evidence to permit a finding of the facts, the weight of the evidence as establishing the facts, the existence of a duty, the general standard of conduct, and the particular standard of conduct against you to win.
The current law stands against you the resident in challenging competency issues as it treats you as a student in this situation. However, it is changing. Just recently, the courts have defined residents as employees for the collection of social security taxes. The hospitals had the temerity to claim residents as students to avoid these taxes.
As the cases meander through the courts, this concept of the resident as a student may change as more and more cases are won on the merits in favor of the resident. At stake on the one hand is the presumed competency of graduated residents which could affect patient care, and on the other hand, the capricious injustice that some residents suffer with a contract termination that could end their medical career without a fair and equitable due process procedure. Imagine a world where one day you are accused of a crime/competency issue, judged and sentenced to a year of hard labor/extended training all by the same person. This scenario occurs in a police state not in one ruled by law. There can be no justice without an objective finding of the facts from which fair inferences could be applied to the premises of justice. Unfortunately, the current system allows the usual cherry picking of inferences that favor the dominant side over the subservient.
Quite frankly, the lack of leadership from the ACGME/AMA for residents in your situation represents an issue of moral legitimacy. The federal government may spend about 120k to 600k on a resident's post-graduate training. The resident may have spent 200k for a medical education. To have it ended in such an arbritary fashion multiplied by several hundred cases a year represents a significant waste of public funds and the infliction of anguish many fold.
The wheels of justice roll slowly but they do roll. Whether ACGME/AMA will lead the way is questionable, but it will face a challenge to its authority in the coming generation if it does not act equitably in this recurring fact pattern.
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A list of what? Programs that have terminated residents?
If so, log on to FREIDA and pull up the list of programs in your specialty. I can almost guarantee you that nearly every residency program in this country has had at least 1 incidence of terminating a resident at some point in time. There are not going to be lists of programs that terminate residents every year, for "unfair" reasons.
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I'm not sure where you get the number of "several hundred" for residents fired/year but lets accept that at face value. There more than 20,000 PGY1 slots in the US. Even if everyone was in a 3 year residency, thats 60,000 residents. If we take your "several hundred" to be 600, my swag is that is a failure rate of approximately 1%/resident/year. So, although I think those are conservative numbers designed to create an overestimate, even if I've underestimated the rate by 100%, does this really seem beyond the pale? I think we fail fewer residents than we should rather than the opposite.
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The fact that this thread has tens of thousands of views just goes to show how much of a problem this is. As a frequent visitor to this forum, I am quite frankly nauseated to see over and over again new threads spring up by former residents who were just booted out of their program, have been put on probation, are afraid of pending probation, or dropped out altogether because of the hell they have been put through with their programs. In any other job if you get fired you can simply get back up on your feet and just work somewhere else. However, this is not the case with residency. It is like being dropped in the middle of Death Valley in the middle of July and left to fend for yourself without any food or water. As has been discussed before on this forum an MD without residency nearly equals a BA degree. Furthermore, you have all the years you already invested into medical school and the six figure debt that does not go away. This is why this is such a scary scenario and sadly it happens way more than it should. By the way, to the guy above who says more people should get booted from programs- please do all future residents a favor and stay out of academic medicine.
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I pretty much agree with this, particularly the part I have bolded.
I personally know someone who was fired from a residency, and he then came to our residency and was one of the very best residents there, and had crazy board scores...and I DO mean crazy, and was clinically good as well. The person was supposedly fired for having bad clinical skills, but I've worked with this person and to put it simply, there's no freakin' way that was the case.
I think a lot of the firings happen because of personality conflicts between the resident and attending(s) and/or other hospital staff. I'm not saying that the fired residents are necessarily blameless in these situations, but I'm sure we can all think of situations where someone didn't succeed in a certain work environment/workplace but then did brialliantly somewhere else. In medicine, it seems like if you end up at the wrong program, or just get off on the wrong foot with the PD or even one powerful attending, or perhaps just in the wrong specialty or one that isn't optimal for you, then you can pretty much just lose everything you have worked for for 8+ years of your life. And then there is the financial side of things that Medicinesux has just mentioned. I don't know what the solution is but there are just some huge power inbalances in these types of situations that make it really, really, really difficult for the resident's side of things to get a fair hearing, IMHO.
I think that residency is like your own private experience, everyone's will be different. And, we are all forged in the hot furnace, or crucible, that is clinical and academic medicine. The pressures, fears and potential conflicts are incredible. We each of us have to bend and flex to fit our own personalities and abilities to the situations we find ourselves in.
What might be a brutally abusive situation to one person, might be a joy ride to another - like Dragonfly says above. How can someone be labeled as clinically incompetent in one place, only to go somewhere else and be clinically a rockstar. It comes down to personalities and doing the best with the situations we find ourselves in. Residency is such an artificial environment, not like any other job or profession. I think it's important to always be mindful of its constraints, and know it is not forever.
What might be a brutally abusive situation to one person, might be a joy ride to another - like Dragonfly says above. How can someone be labeled as clinically incompetent in one place, only to go somewhere else and be clinically a rockstar. It comes down to personalities and doing the best with the situations we find ourselves in. Residency is such an artificial environment, not like any other job or profession. I think it's important to always be mindful of its constraints, and know it is not forever.
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Yes, and another thing is that when you go to interview for med school and/or residency, it's really important to listen to your gut r.e. where you'll "fit" and not feel pressured to try to attend what someone else says is the "best" program. Sometimes you can still make a wrong choice, but in general I've found my gut feelings to be pretty accurate, and when I disregarded them I ended up unhappy and when I listened to them I ended up in better work or school situations. Just my opinion. It doesn't really help people who are already in the crappy/bad position.
Despite of these, there are still no advocate for residents in the system especially from those already completed residency ,survived in this horrible situation. These problems which has been going on for years will generate more and more dropouts and the authority( which responsible for accreditation for programs) still ignore its existence.
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There are no perfect systems, just like there are no perfect people.
Also, I think that there are residents who academically have a lot of problems because they were on the lower end in terms of knowledge base (i.e. barely passed USMLE, like some US students who struggled in med school and/or had to go abroad such as to some of the Caribbean med schools) and/or they have problems with their English and maybe cultural issues with knowing how to relate to patients or hospital attendings and coworkers (latter applies more often to some FMG's for whom English is not their native language). But I think that even residents who struggled at one program might do just fine in another program...maybe another specialty altogether. But because of the way our system is set up, if a resident gets booted from one program, that is such a black mark that he/she often has huge problems getting into another one. Still, if you were a program director in the position of picking new residents, who would you pick - someone who has already been booted from a program, with a 199 Step 1 score, or a fresh, shiny new graduate with a 199 USMLE score and no negative references? It is a problem for which no easy solutions are available.
There are organizations available to address these problems. AMSA, AMA-MSS and AMA-RFS, perhaps the ACGME. I think there are things we can address, such as the way some programs drag their feet in producing required documentation (i.e. won't produce documents stating how many months of training a past resident has completed and gotten credit for). This happens not only with residents who got fired or quit in the past, but also with ones who transferred from one residency to another. Some programs are just disorganized, but sometimes they do it I think out of spite or because their lawyers drag their feet for months deciding what info they can release and what they cannot or will not.
Also, I think that there are residents who academically have a lot of problems because they were on the lower end in terms of knowledge base (i.e. barely passed USMLE, like some US students who struggled in med school and/or had to go abroad such as to some of the Caribbean med schools) and/or they have problems with their English and maybe cultural issues with knowing how to relate to patients or hospital attendings and coworkers (latter applies more often to some FMG's for whom English is not their native language). But I think that even residents who struggled at one program might do just fine in another program...maybe another specialty altogether. But because of the way our system is set up, if a resident gets booted from one program, that is such a black mark that he/she often has huge problems getting into another one. Still, if you were a program director in the position of picking new residents, who would you pick - someone who has already been booted from a program, with a 199 Step 1 score, or a fresh, shiny new graduate with a 199 USMLE score and no negative references? It is a problem for which no easy solutions are available.
There are organizations available to address these problems. AMSA, AMA-MSS and AMA-RFS, perhaps the ACGME. I think there are things we can address, such as the way some programs drag their feet in producing required documentation (i.e. won't produce documents stating how many months of training a past resident has completed and gotten credit for). This happens not only with residents who got fired or quit in the past, but also with ones who transferred from one residency to another. Some programs are just disorganized, but sometimes they do it I think out of spite or because their lawyers drag their feet for months deciding what info they can release and what they cannot or will not.
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I admittedly have not read every post within this thread. However, must agree some folks should be terminated. I think it is far more cruel to drag someone along and then terminate after 2 or 3 years. It is unethical to continue someone and graduate them when they are not competently trained. There is absolutely no room in medical training/residency for "social promotion". There are unfair terminations...YES. But, if you look at the post above and in particular, the highlighted portions, the poster fully admits to all the deficiencies listed in the evals he/she was provided. Furthermore, it would appear at best he/she could only hope for being given a "do over" year!!! It may seem socially "fair" to give you a repeat year. However, as an administrator, it is stupid. That is an enormous amount of funding to remediate a resident at the expense of potentially new categorical applicants from the upcoming medical class. Receiving the generous opportunity to repeat a year may be good for the individual but it is not necessarily good for the program or the patients.
The number of visits to this thread or any other does not equate any amount of "evidence" or "proof". At the very least, in reference to the post I noted above, the individual fully admits to such a level of deficiency that starting over was warranted. If someone is not even performing up to par at the level of a PGY1, it is potentially unsafe for them to remain. No PD or hospital should wait for a patient injury to make this decision. The poster him/herself readily admits to this level of deficiency. It would be nice to be given the gift of a re-do. But, just because you have spent money to get to the point you are, it does not mean you are qualified for your position or that you have received an adequate education to provide care as a physician. The true injustice is to graduate someone from a medical school foreign or domestic when that individual is not qualified. There are too many folks moving forward/up in a system of inflated grades and too many unqualified folks walking around with diplomas...
JAD
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This is a pattern that marks pretty much everything in life. Relationships are never as smooth as the movies lead you to believe, being a doctor isn't as exciting as ER and House lead you to believe, and being an adult is frequently not as cool as you were told it would be when you were a kid.
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I was recently asked by my chief resident to come in about my poor inservice exam scores. I actually would have studied, but we were told that the grades mean NOTHING. I did it post call, exhausted, skipped alot of questions and passed out.
I'm not on probation, but I think its been hinted that if I don't shape up and start improving my academic calibar I might 'not progress' onwards. my evals have been great (no deficiencies). But I think a few people have said things behind my back 'off the record here and there' and its being brought into light now.
I feel like my whole world is crashing around me, but I'm going to do something about it. I'm going to study HARD, I'm really going to try, worse comes to worse I'll fail but at this point I have very little to loose.
Sigh....
depressed..... what else is new.....
I'm not on probation, but I think its been hinted that if I don't shape up and start improving my academic calibar I might 'not progress' onwards. my evals have been great (no deficiencies). But I think a few people have said things behind my back 'off the record here and there' and its being brought into light now.
I feel like my whole world is crashing around me, but I'm going to do something about it. I'm going to study HARD, I'm really going to try, worse comes to worse I'll fail but at this point I have very little to loose.
Sigh....
depressed..... what else is new.....
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This is a surprising trend that I hear often..... Please, if I can convince medical students and residents of only one thing, it is that "objective" examinations, even if you don't like them do matter. It is said too often that "being a team player, being a hard worker, and/or being a "nice guy" is more important then the in-service exam...". Do NOT believe it; Buyer beware!!!
As a medical trainee, you are there first and foremost to be trained in both the technical AND cognitive components of your given specialty/discipline. As a trainee, putting the patient as first priority, by definition, MANDATES that you read and study so you are as clinically competent as possible.... it does not mean sitting at the patients bedside holding their hand. In the end, "nice guy" on a "subjective" evaluation form from an attending that you did not wake-up at 2am does NOT overcome a black and white numeric value on the in-service exam. My local grocer is a "nice guy" but that does not mean I want him taking care of my grandma during an emergency.
We can argue the validity of in-service exams all day long. However, there are surveys and studies suggesting a minimum performance on these exams translates to ability to achieve board certification (i.e. ???minimum fund of knowledge and clinical judgement).... "nice guy" translating to successful board certification has NOT been demonstrated. Residency is a package deal. I can not speak for any other specialties' in-service examination other then surgery. And, for surgery, I have to tell you that is a VERY, VERY studiable exam. With the exception of the exceedingly rare minority, all residents are adults. Get your old questions and study. Get your review books and study. The score on that exam can be your shield or it can be your PD's axe. The choice is yours.
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This first statement is illogical -- I'm a medical student and felt compelled to open this thread just because it's a pretty racy topic. I would assume that a good chunk of the views come from the usual seeking for drama, entertainment and voyeurism on SDN and not because people are actually dealing with this situation personally. However, you did point out reasons why this thread is so interesting -- being kicked out of residency would be pretty horrible for most of us, so we fear it even if the odds are pretty low.
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Couldn't have said it better myself... I WISH I knew this coming into residency. I guess I was sooooo naive. If I knew I would have studied from day one, not done the exam postcall, skipping 30 questions to get out early and sleep after 40 hours of pure exhaustion. I pray I did better this year. We'll see, I was at least awake! but more than anything am annoyed at myself for not taking this more seriously. I've never done badly on an exam, in medical school or college, I should have realized residency would be no different. We were just repeatedly told that this was not going to count... all I can say is DUH!
don't make the same mistake that I did! do study!
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EXACTLY!!! I never understood how presumably smart people, presumably the upper end of intelligence and education, presumably folks that have spent years and years developing study habits and test taking skills.... suddenly get into residency and become "dumb". Your need to study does NOT end when you start residency. At the very least it INCREASES. You are now a physician. Your patient's lives now depend on you having read and having the right answers.
The level of responsibility changes exponentially when you go from medical student to MD/DO. That exponential change continues when you go from trainee license to "unrestricted" license. It further continues when you go from trainee/rsident to ATTENDING. Do NOT fall for the trap or take the bait of... "being a nice guy/gal" is what is most important.
You need to be a good doctor first.... yes, bedside manner is important, but a "nice guy/gal" at bedside that doesn't know what they should is dangerous.... especially since they might get more patients referred because they are "nice" even as they are incompetent.
Please, please, please..... continue to study. It is the right thing to do for you and most importantly your patient/s.
JAD
PS: have some pride too. I don't understand how someone that maintained 4.0 status in undergrad, went AOA in med-school, etc would accept below average test performance in residency. It should be very, very embarassing.
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You are completely right! I think the problem (my reasoning anyhow) is that internship can be brutally difficult/sleep depriving. Plus in my case (not to make an excuse) I had many other personal issues going on which killed my time.
Nevertheless, I've decided to rectify things this year. Instead of just whining I'm actively studying, getting back to my roots; meeting with attendings to go over material and strengthen my medical knowledge overall. I actually think I'm improving. I'm lucky that all my evals are at least passing or excellent. For me its mainly my in-service exam score last year which I did 30 hours post-call. I figured I basically have two choices: quit or keep going and I'm just going to keep going and do my best. For myself and my patients!
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yes, john needs to study. However, I too was told that the in training exam score didn't "count" in any way for promoting residents and that it was SOLELY used in our program for the resident's personal use to know what to study (i.e. self-identify deficiencies). The ABIM also says that the test is primarily for identification of deficiencies so the resident knows what to study and isn't supposed to be used to "rank" residents per se.
Also, when I took the test as an intern I was also postcall and had gotten NO sleep the night before...this wasn't the case for at least 3/4 of the other interns...not surprising that those of us with no sleep didn't do quite as great. We also were only allowed 2 hrs to take the test, while some other programs gave 2.5 hrs or 2 hrs 15 mins...so not a level playing field. So I got a pretty average ITE score...although I don't consider average/50th %ile to be that crappy...though was not pleased with the score in general. But what I WAS surprised about was how the PD came back and used the exam to pretty much threaten me with...if he planned to use it that way then he should have been honest about the fact that it counted, it was being used to decide who was a "good" resident and who was not, it was used for other purposes, etc. I sure didn't make the mistake during 2nd/3rd year of thinking the test was only for general identification of deficiencies, b/c I got the picture...it was pretty much used to rank people. The surgical programs are more up front about this, but sometimes in IM people are more passive aggressive and they claim the test isn't to be used to rank people and then they do just that. So beware...
Also, when I took the test as an intern I was also postcall and had gotten NO sleep the night before...this wasn't the case for at least 3/4 of the other interns...not surprising that those of us with no sleep didn't do quite as great. We also were only allowed 2 hrs to take the test, while some other programs gave 2.5 hrs or 2 hrs 15 mins...so not a level playing field. So I got a pretty average ITE score...although I don't consider average/50th %ile to be that crappy...though was not pleased with the score in general. But what I WAS surprised about was how the PD came back and used the exam to pretty much threaten me with...if he planned to use it that way then he should have been honest about the fact that it counted, it was being used to decide who was a "good" resident and who was not, it was used for other purposes, etc. I sure didn't make the mistake during 2nd/3rd year of thinking the test was only for general identification of deficiencies, b/c I got the picture...it was pretty much used to rank people. The surgical programs are more up front about this, but sometimes in IM people are more passive aggressive and they claim the test isn't to be used to rank people and then they do just that. So beware...
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Memories are quite short..... remember that little series of examinations under the heading of USMLE? Those too are really suppose to be meant as a "pass/fail" assessment. They are/were not intended to be used as a "ranking tool".... You take that test and a score results next to your name.
You need to decide if that score is respectable or not. Or, you can take a path of rationalizing low scores or pushing the belief in a lack of importance of those scores if that makes you happier.
Just study.
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I think there are some differences between USMLE and ITE. USMLE scores are specifically released to residency programs, and applicants know that. The internal medicine ITE is specifically NOT allowed to be released (say to fellowship programs) and that does help somewhat in preventing it from being used to rank applicants. For example, no fellowship program asked for a copy of my ITE exam scores, and the PD was not allowed to give these out. Not so for USMLE. USMLE also requires some level of thinking, which IMHO the IM ITE didn't really...pretty much 95% memorization IMHO. The internal medicine boards were a bit better in that regard.
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So be it... I suspect, if a PD is worth any credibility, how well or how poor will effect the quality of a letter he/she may write on your behalf without even putting the score. Also, phone calls are made and "unofficial" comments will occur. What you may believe is a strong letter may in the world of PDs and Fellowship directors actually be "code" for OK, but not my greates hope for the future... PDs have become very atune to how to phrase things in order to send a message without outright stating the obvious.
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IM is a little different than surgery and anesthesia, in I think that test scores aren't usually seen as being quite as important. It does depend on the fellowship program, though, as well as the specialty. GI and cards and hem/onc can be more picky that rheum and endo, so they can pick out the applicants with the most research and highest test scores, etc. Personally, I had pretty good USMLE scores and I used that to try and help my cardiology application. However, I feel like it wasn't much of a factor at most of the programs where I applied...I think they were looking more at other things...research and LOR's matter more for cardiology, as well as where an applicant did residency. However, there are definitely programs that screen with USMLE scores...though not as many as there are during residency application. I think it's because they have more stuff to judge applicants on at this point, whereas during residency application they mostly have grades (which vary a lot from school to school), LOR's (which tend to look similar for many applicants) and USMLE scores.
I'm not trying to argue that the OP doesn't need to study, I was trying to reassure the OP that 30th %ile doesn't mean the OP is destined to fail out of residency and fail the fp boards. It's just a warning to ramp up the studying and increase his/her knowledge base. I'm not sure what the failure rate is for fp boards, but if it's similar to IM then only about 10% of people fail on their first try, so if he/she starts studying more now, things should be O.K. I've heard that a lot of fp people study something called Swanson's Family Practice for boards and the ITE, but I really don't know. Personally I found that just finding out what book(s) other people were using to study was helpful...for IM it's generally the MKSAP put out by the folks who make the ABIM exam, or the Medstudy books that are sold for around $500 for the set.
I'm not trying to argue that the OP doesn't need to study, I was trying to reassure the OP that 30th %ile doesn't mean the OP is destined to fail out of residency and fail the fp boards. It's just a warning to ramp up the studying and increase his/her knowledge base. I'm not sure what the failure rate is for fp boards, but if it's similar to IM then only about 10% of people fail on their first try, so if he/she starts studying more now, things should be O.K. I've heard that a lot of fp people study something called Swanson's Family Practice for boards and the ITE, but I really don't know. Personally I found that just finding out what book(s) other people were using to study was helpful...for IM it's generally the MKSAP put out by the folks who make the ABIM exam, or the Medstudy books that are sold for around $500 for the set.
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UPDATE from Aucdiver:
I'm not sure if anyone is still following this thread, but here goes. After being released from my FP residency after the 2nd year and being unemployed for 14 months I was finally accepted into an Urget Care/Occupational Medicine part time position in Wisconsin. I worked there for 6 months and really enjoyed it. I left this part-time job to join the USPHS
I've been in the PHS for a year and a half now, and have enjoyed every minute of it. I now work at a maximum security federal prison, seeing about 8-10 patients a day. I take call every 3 weeks and hardly ever have to work off hours. Prison medicine isn't for everyone, but I really enjoy it. After my 2 year commitment is up I plan to re-apply for residency.
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Thank you for your post. I think it is good to hear first hand that people can move on after such a dire event.
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1. Yes, but it's completely ethical to dump someone on their ass after:
A. They take a substantial loan out for a degree that is useless outside of their field. Most people in medicine (especially at the PGY1 stage) lack business acumen and technological aptitude, so for them moving laterally (ie: to industry) is not feasible.
B. They supposedly are working on bettering themselves:
C. They were told they have a job, but not necessarily a promotion to PGY2:
You expect perfection from all your medical staff, a policy with which I agree. However, when a person screws up and is working on it, you refuse to give them any help. Had the poster in question been flagrant about his/her dismissal, been a detriment to staff, or caused serious medical problems, I'd be disinclined to offer any help. Instead we have a case of someone not as knowledgeable and not as quick, but working on both issues. What more do you want?
2. If your program has Caribbean students filling in PGY1 IM slots, you weren't going to have many [competitive] categoricals anyway.
i have a freind who also went through this problem. he finished family medicine 1 yr and 4 months with almost all good evaluations and one or two evaluations with remiedeation but passed completely. but he had some personality issues with 2 OB rotations at 2 different places. and the funny part is many other FMG's have had problems with working in those 2 OBGYN rotations. this friend of mine is great in clinical knowledge and patient care, and as far as I know many of attendings liked him, and almost all aptients loved him, he has awesome scores in USMLE Step 1 and 2, and passed all steps 1,2 , 2cs in first attempt, he was also great medical student in our medical school in foreign medical school. this was so unexpected for him, that he feels so bad now. any advice suggestions for him.
Amen. I'm also a frequent visitor and infrequent poster that finds the posts crucifying every terminated/near terminated resident that are in dire straits and just asking for advice absolutely nauseating. These residents need constructive, professional advice in good faith, with some benefit of the doubt. Instead, they receive incendiary replies that essentially reprimands them for being in a situation that all of us know, deep down, could hypothetically occur to the most clinically competent resident. You've made your points beautifully.
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http://www.fsmb.org/usmle_eliinitial.html
This link shows which states require 1, 2 or 3 years of residency, the cost of each state license and which ones accept FCVS.
It's very important that you complete at least one year of residency, get that PGY1 certificate, pass Step3 and then apply to a state of your choosing that meets the criteria that you have accomplished. Wyoming and Wisconsin only requires completion of PGY1. Wisconsin's license is <$200 and Wyoming's is $400.
Once you have a state license, look for part-time work in Urgent Care in that state, or look into working for USPHS, like I did. http://www.usphs.gov/
Don't waste your time with recruiters - they won't help you if you are not BE/BC. Don't waste your time with working at a VA - same reason. Don't expect to find a full-time job after not completing residency until an employer gets to know you. Jobs are out there for those of us that didn't finish. You just have to look in the right places. I personally recommend working in a prison, but I like a challenge. Prisons are always hiring.
YOU CAN RECOVER FROM THIS!
Good luck to all! Don't forget to exercise. It's the best medicine for depression.
This link shows which states require 1, 2 or 3 years of residency, the cost of each state license and which ones accept FCVS.
It's very important that you complete at least one year of residency, get that PGY1 certificate, pass Step3 and then apply to a state of your choosing that meets the criteria that you have accomplished. Wyoming and Wisconsin only requires completion of PGY1. Wisconsin's license is <$200 and Wyoming's is $400.
Once you have a state license, look for part-time work in Urgent Care in that state, or look into working for USPHS, like I did. http://www.usphs.gov/
Don't waste your time with recruiters - they won't help you if you are not BE/BC. Don't waste your time with working at a VA - same reason. Don't expect to find a full-time job after not completing residency until an employer gets to know you. Jobs are out there for those of us that didn't finish. You just have to look in the right places. I personally recommend working in a prison, but I like a challenge. Prisons are always hiring.
YOU CAN RECOVER FROM THIS!
Good luck to all! Don't forget to exercise. It's the best medicine for depression.
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A Resident who is fired from residency program can apply to state medical board license based on number of years successively completed on training from ACGME approved programs. Some states require only one year, some two and majority three years. The job of the State medical board is to make sure these physicians are safe when dealing with the public, they should not be issued license, if there is any problem beyond reasonable doubt, in the assessment of their respective state medical board. These folks will be unleashed to treat humans fellow Americans.
From market point of view, most hiring vendors require BE/BC for malpractice insurance, hospital privileges, etc. so the fired resident, still with a license, will have great difficulty finding a job compared to those with BE/BC. There is some good reason(s) why a resident will be fired, at least from PD point of view, and most program directors carry responsibility of protecting the public as well, and weed out those who may provide risky practices.
At the end of the day they will find some way to treat patients and make living for themselves and families. The question is there any discrepancy between the state medical board assessment and residency program directors?
If these physicians will treat humans regardless, and the residency program directors opinion is valued, is there any moral obligation to provide tools, career counseling and modification to accommodate these physicians for public safety and government money spend wisely.
Does the residency programs, including PDs, make the conscious decision and selection to hire these residents but seems not good enough judgment vis-a-vis firing them at the end. What is moral obligation for these residency programs in facing this public problem that seems to be increasing? Some may argue this resident need to be fired, even the reasons does not qualify the criteria of state medical board (e.g) unprofessional conduct based on learning disability, etc.
IMHO there seems to be failure on creating true checks and balance system in the United States GME, and there seem to be health business factor as well as many human factors including doctor persona and egotism that result in wasteful resources. I hope the current financial crises and health care reform will address these issues more closely.
From market point of view, most hiring vendors require BE/BC for malpractice insurance, hospital privileges, etc. so the fired resident, still with a license, will have great difficulty finding a job compared to those with BE/BC. There is some good reason(s) why a resident will be fired, at least from PD point of view, and most program directors carry responsibility of protecting the public as well, and weed out those who may provide risky practices.
At the end of the day they will find some way to treat patients and make living for themselves and families. The question is there any discrepancy between the state medical board assessment and residency program directors?
If these physicians will treat humans regardless, and the residency program directors opinion is valued, is there any moral obligation to provide tools, career counseling and modification to accommodate these physicians for public safety and government money spend wisely.
Does the residency programs, including PDs, make the conscious decision and selection to hire these residents but seems not good enough judgment vis-a-vis firing them at the end. What is moral obligation for these residency programs in facing this public problem that seems to be increasing? Some may argue this resident need to be fired, even the reasons does not qualify the criteria of state medical board (e.g) unprofessional conduct based on learning disability, etc.
IMHO there seems to be failure on creating true checks and balance system in the United States GME, and there seem to be health business factor as well as many human factors including doctor persona and egotism that result in wasteful resources. I hope the current financial crises and health care reform will address these issues more closely.
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What? It's a little early to be that drunk don't you think?
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If you review some of (his/her) comments in sdn you may recognize Bullying attitude and behavior combined with doctor persona and cultural insensitivity.
Thank you gutonc for being classical and living example, Scary!
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It is certainly true that residents who are terminated with some training can apply for a medical license. Most boards require only 1-2 years of GME training before issuing a license for US grads, many boards require 3 years for IMG's. However, boards look at more than just years completed. If a resident were to complete 2.5 years and and get terminated for a professionalism problem (for example), the board would likely hear about that when they request a summary of training and could decline to issue a license.
Yes, the primary purpose of the medical board is to ensure quality in those practicing in that state. We can argue whether they need to find "reasonable doubt" before denying a license. Reasonable doubt is a legal term for a jury to find a defendant guilty. Medical boards may use a lower standard.
Yes.
Also agreed. There needs to be a mechanism by which residents who cannot perform satisfactory work are not promoted / graduated.
This is not exactly true. Yes, with a license and without BE you can try to find some work, and if you're creative you can likely be successful. However, as above it might not be possible to get a license without completing training satisfactorily.
Maybe, but they are (perhaps) assessing two different things. Let's assume a state medical board requires 1 year of GME to get a license. The State board is using a standard of "minimal competence" to get a license. The board says that the resident can work as a physician in an unsupervised setting, while the rest of the medical establishment (i.e. most insurance companies, hospitals) feel that only completion of a residency shows the minimum amount of competence to practice. I'm assuming that your point is that, if a state is willing to license a physician, which means that they can practice unsupervised, doesn't that mean that a residency program should take them and continue to train them further. I disagree with that notion.
Also, I think it's fair to say that physician licensing laws have likely fallen behind the times and haven't been updated. If someone took a long hard look at this, they would likely limit the ability to practice after only 1 year of training.
I guess what you're saying is: "Since these physicians will be licensed and therefore treating patients, and a residency PD felt that they were 'incompetent', doesn't that create a double standard?" If residency PD's fire them, presumably there was some problem with their performance. Hence, the "gov't" (whomever that is, exactly) should find a way to help such people because it's dangerous for them to practice medicine unsupervised.
I agree that there is a double standard. I would argue that it's the state licensing boards that have the wrong view, and should be changed. The number of options that licensed but unboarded physicians have is shrinking, so the problem is "solving itself".
Also, as mentioned above, if you get fired from a residency program for a serious problem, often it's difficult to get a license even if you have the minimum training.
Huh? I hire someone, they have a serious problem, I try to help them fix this problem, it doesn't get fixed, and I fire them. I don't see the judgment problem there. We can debate the checks and balances in the system (later in your post)
First, it's not clear to me that this problem is increasing.
Second I don't see any moral obligation. As mentioned, if when I terminate you I don't think you are safe to practice as a physician, I put that in your final evaluation. All state boards will request this as part of the licensing process, and would prevent you from getting a license (without further training). If I fired you but felt that you would be safe as a practicing physician (i.e. perhaps you had untractable communication problems with peers, or a professionalism problem that didn't put patients at risk), then I'd document that and leave it up to the board.
The state medical board doesn't set criteria for firing patients.
More importantly, learning disabilities do not explain nor excuse professionalism violations.
There is no question that residents do not have much protection from programs that wish to terminate them. Most programs have an internal appeal process, but we all know that's only as honest as the program is. It's a tough issue -- programs must be able to protect the public from dangerous doctors. Having some sort of an independent review of a resident's performance is very difficult if not impossible -- an outside reviewer would simply read reports from people whom worked with the resident (and presumably some explanation from the resident themselves) and you have a GIGO problem (Garbage in, Garbage out). A program could magnify a resident's deficits in it's reports. Faced with some reports that say a resident is terrible and dangerous, and other reports that say he is "outstanding", what's the right thing to do? If you put public safety first, you believe the reports of concern. I can tell you that the "worst" residents can always find someone to say something nice about them. Performance varies across time, space, acuity, etc, so someone doing well on one block doesn't "negate" a concern from a different experience.
However, there are certainly some cases of residents terminated unfairly. How to address this without creating a ridiculous beurocracy, I have no idea. Also, let's be clear that many residents who feel they were terminated unfairly have poor insight.
Health care reform is certain to change many things. Deciding what to do with residents who are terminated from training is not one of them. We have much bigger problems to "solve".
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I think a little was lost in translation.
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Thank you PD for your civilized response and elaborate in my <snip...a bunch of rambling crap that made no sense>.
I hope this will be teaching opportunity to someone, I doubt (his/her) courage out-weight ego and apologize;
speaking about professionalism!
I hope this will be teaching opportunity to someone, I doubt (his/her) courage out-weight ego and apologize;
speaking about professionalism!
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I think termination shouldn't be allowed in residency, due to the capped funding. where is a resident going to go if they can't ever get back in again because they used up their funding?
if there is to be termination, then there shouldn't be any capped funding, we should be free to go to whatever program we please, without funding issues. However, until then, termination shouldn't be an option. it is too unfair. and many get terminated per year, so this shows many residents are screwed out of becoming a doctor due to this capped funding.
if there is to be termination, then there shouldn't be any capped funding, we should be free to go to whatever program we please, without funding issues. However, until then, termination shouldn't be an option. it is too unfair. and many get terminated per year, so this shows many residents are screwed out of becoming a doctor due to this capped funding.
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Well, If you look at some of the preventive medicine residency programs, they don't seems to worry about the GME funding, they have greater tendency to enroll those who already completed general specialty, FP, IM, Peds etc..that include who were terminated from residency programs..
Guess what, they offer MPH as part of their residency, which means they cover the expensive tuition fees as well, another funding issue. They spend two years and become BE/BC and move on with their career. I suggest to those who are interested to volunteer few hours weekly, if that possible, and help at your local health department, check if preventive medicine suitable for you and take it from there.
There is also alternative pathway to become Board certified in preventive medicine.
https://www.theabpm.org/requirements.cfm
Those who want to go further in their education may try fellowships (subspecialty) in (a) Medical Toxicology (b) Undersea and Hyperbaric Medicine. Life is good, there is other ways..
https://www.theabpm.org/medtox.cfm
https://www.theabpm.org/uhm.cfm
Guess what, they offer MPH as part of their residency, which means they cover the expensive tuition fees as well, another funding issue. They spend two years and become BE/BC and move on with their career. I suggest to those who are interested to volunteer few hours weekly, if that possible, and help at your local health department, check if preventive medicine suitable for you and take it from there.
There is also alternative pathway to become Board certified in preventive medicine.
https://www.theabpm.org/requirements.cfm
Those who want to go further in their education may try fellowships (subspecialty) in (a) Medical Toxicology (b) Undersea and Hyperbaric Medicine. Life is good, there is other ways..
https://www.theabpm.org/medtox.cfm
https://www.theabpm.org/uhm.cfm
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Yes, but what about those residents who are downright incompetent and lazy? You should give them some chances to improve, but what if after you've done all that, they still don't change their ways? There are some who are not committed to doing better, who don't study, and who are sloppy in their patient care duties. You need to have some way to get rid of lousy residents before they endanger a patient. If they are that way, I don't think we should be allowing them to get into another residency.
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Some residents are lazy and some are incompetent. Some manage to pull of being both, although that is rarer. Med school does a good job of screening out laziness and a slightly less good job of screening out incompetence. But it's not a perfect process. People that are not suited to the practice of medicine graduate medical school, sometimes with impressive seeming stats.
Some people respond well to the carrot and stick of grades and less well to the ambiguity of the workplace, even with attempts at providing regular feed-back. The same student that wouldn't tolerate a "C" and would do anything to change it may not realize that an evaluation pointing out significant deficiencies is a big deal.
There is nothing in medical school that quantifies "giving a s**t" about the patient. In fact, the student that doesn't interact with patients on more than a superficial level is likely to score higher on the shelf exam because of increased time to study. Also, as you found out, residency is significantly more stressful than medical school for most fields. The uncertainty and lack of experience involved in dealing with sick patients, combined with necessarily imperfect back-up systems places a toll on trainees that medical school doesn't. I'm sorry to hear clinical medicine didn't work out for you, but you've got some ideas that just don't mesh with reality.
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Yes, I am one such resident who was grossly abused by a residency program and then terminated. The psychological effects are unbelievable. It is just like you said, once you are fired, its like paddling up a creek without a paddle. I was a great physician, I just started out wrong because I was pregnant and had issues when I came back from maternity leave. I took another two week leave and came back doing great but, the program continued to discriminate and use the past against me. It is a shame what these people do to other people. I would really take all the responsibility if I was genuinely a bad resident but I wasn't. Compared to my class I was one of the better ones. But they continued to pass those people and harass me. I am ready to make a change and rejoin my career but can anyone out there help me? I had no problems with gaining a residency after graduation so my scores and records were OK. Its just moving on from this blunder that has destroyed my career and I am still struggling to come out of it.
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