How often have you seen residents fired purely for competence issues related to medical knowledge or workflow without any overlying professionalism issues? I’m thinking of a resident who shows up on time, is respectful of colleagues and patients, and asks for help when needed, but for whatever reason just cannot get the work done right.
Fired for incompetence
- Thread starter odyssey2
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I think we had a similar discussion in another thread, but just to carry it forward here:
Hard to separate the two. The incompetence typically leads to compensatory behaviors that are unprofessional. People lie or cut corners and that eventually gets them found out.
Someone would have to be an incredible actor with nerves of steel to feign confidence when they were truly incompetent. My sense is this is the kind of thing that happens with the Dr Death types who somehow manage to slip through. Even so, it’s rare.
Hard to separate the two. The incompetence typically leads to compensatory behaviors that are unprofessional. People lie or cut corners and that eventually gets them found out.
Someone would have to be an incredible actor with nerves of steel to feign confidence when they were truly incompetent. My sense is this is the kind of thing that happens with the Dr Death types who somehow manage to slip through. Even so, it’s rare.
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Agree with above and would add that pure incompetence without mental health issues that are untreated (anxiety, adhd, depression, any of it) would be really rare. A conscientious person who does the work I find wouldn’t actually meet the definition of incompetence. Interns don’t have the knowledge or experience but basically never fail to make that up as time progresses.
To say it another way, basically everyone is incompetent when they start and that’s the point. Its the professionalism (for lack of a better word, but it probably goes beyond just pure professionalism) that brings you out of incompetence and into being on track to practicing solo.
To say it another way, basically everyone is incompetent when they start and that’s the point. Its the professionalism (for lack of a better word, but it probably goes beyond just pure professionalism) that brings you out of incompetence and into being on track to practicing solo.
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I have seen it. It's a much slower way to get fired than for professional issues. You get lots of chances to prove you're progressing and to get help with it, but at some point, if you don't develop the clinical knowhow, you can't be promoted to the next level.
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I heard third hand of a surgery resident let go a few years in for just not being able to do the work, apparently well regarded as a human just not as a surgeon and they worked to help a transition into a non surgical residency
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We have a resident in my program who had to repeat a year and in my residency I had a coresident who had to repeat a core rotation. Neither case was due to unprofessionalism. (Obviously none of us were in the discussion with our coresident but it was obvious to us they were behind clinically and we didn’t really hear about any drama, so it’s an educated guess the repeat was for clinical skills.) I agree that it’s much harder to fire someone for this and programs would typically want to retain their workforce and help you as much as possible.
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I knew one intern that wa flat out bad. Failed her boards and barely sneaked by on retake. Came in with pretty horrible clinical judgement. Was also lacking common sense. She had to have someone cover overnight with her out of concerns she’d kill someone. Not sure if she eventually made it through. But she is the only one that I’ve know that really shouldn’t have made it to residency and did. I’ve known a handful of integrity/work ethic concerns but that’s much more common than knowledge base concerns, I’d imagine.
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I have seen it precisely once, when I was a resident. An intern had unfortunately decided to stop taking medication for ADHD around the same time that intern year started and it did not go over well. Super nice person, patients loved them, they just took forever to get things done and couldn't be trusted to follow-up on or remember things in a high stress work environment. I think they switched specialties and are doing better now somewhere else...
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This is how a resident was fired when I was in my chief year. Or shortly thereafter, anyway. She had 100% confidence in her decisions, but they were often wrong. She wasn't ~acting~, however. She sincerely believed everyone was just bullying her and never recognized her own incompetence or could understand why her ITE scores were like 1st percentile.
Where I trained, it is actually quite difficult to be fired. She worked hard at it for 3 years before it finally happened.
It's not like she dropped a lung putting a central line in and was immediately fired. We expect people to F up. It's a part of learning. But you have to actually learn from mistakes, not make them again and again and again.....therein lies the difference. So many people are great book learners their entire life, and residency is their first "real job." Without a solid work ethic you're doomed or at least predisposed to being doomed.
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it’s kind of a semantic point and not worth belaboring really but this story sort of goes to my point that there’s a professionalism-ish aspect to all of these stories at the end of the day. Complete incompetence despite feedback and not learning from mistakes reveals a deeper issue, in my mind. Might not be exactly the same as lying or showing up super late or having anger management issues but still make the workplace difficult and the job a dangerous one and it depends on how the person responds to recommended intervention.
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From reading this forum for the past several years, I have enough seen stories of people getting fired for being unteachable, and more for the "what doctors need to know" part, rather than the "how doctors need to act part". Although the latter is far more common, it seems.
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One colleague was invited to leave the program at the start of our third year and as far as I ever heard there were no professionalism issues. However, this person was a) very weak clinically and incredibly awkward with patients (which is a problem if you're a psychiatrist) and b) utterly impervious to feedback. Our program had to have a senior resident paired with them on rotations involving any acuity as a backstop to their decision-making, and I think the problems became insurmountable after they were on our very busy consult service and had to be pulled because of the ludicrous recommendations being made to primary teams. The week before they were let go they told me that all the remediation they had to do was just because they had made a negative comment in a class about some attending's pet therapeutic model. As far as I know they left medicine. Perfectly nice, just...very clueless and not able to willing to incorporate attempts to educate them.
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Out of curiosity can you please give an example of what constitutes a psych "ludicrous recommendation"
You can't just tease those kinds of details
You can't just tease those kinds of details
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Yeah. I agree with you and others that being able to accept and incorporate feedback, and learning from your past mistakes, is key in this type of situation.
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We had a couple residents leave/were fired during training.
One I'm not entirely sure what happened. I know they failed a rotation intern year (because my schedule was rearranged because of it). Very nice, great to work with, but I'm guessing there were lots of medical knowledge issues and concerns about being a senior resident. Last I heard, they were going into occupational med.
One had horrendous clinical decision making. Like could be talked into any decision and didn't understand the nuances of medicine. Very rigid in following protocols, but didn't understand when they had to deviate from the protocol or the differences in risk factors. Also, lacked insight pretty bad--kept insisting that things weren't the way we interpreted them to be.
We had several people that had to have remediation in one form or another during residency, but the vast majority of them got through training.
So, it would take a lot for competence only issues to result in termination, but not unheard of. It's typically coupled with some sort of professionalism issue.
One I'm not entirely sure what happened. I know they failed a rotation intern year (because my schedule was rearranged because of it). Very nice, great to work with, but I'm guessing there were lots of medical knowledge issues and concerns about being a senior resident. Last I heard, they were going into occupational med.
One had horrendous clinical decision making. Like could be talked into any decision and didn't understand the nuances of medicine. Very rigid in following protocols, but didn't understand when they had to deviate from the protocol or the differences in risk factors. Also, lacked insight pretty bad--kept insisting that things weren't the way we interpreted them to be.
We had several people that had to have remediation in one form or another during residency, but the vast majority of them got through training.
So, it would take a lot for competence only issues to result in termination, but not unheard of. It's typically coupled with some sort of professionalism issue.
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I'm ED not psych, but one of our psych residents had to repeat an ED month because they were recommending admission for anyone who said they were having suicidal thoughts (including the dude there every day who recanted after a breakfast box).
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1 from my residency was finally terminated more than 1/2 way through 3rd year. He was remediated multiple times by the program however he still just did not have the common sense factor. Quite scary as a intern, let alone when the residency allowed him into second and third year as a senior resident managing an inpt team. He was attempting to get a fellowship, I think hospice, he was unable to grab one, and then weird enough the residency terminated the individual few short weeks later. Almost felt bad for the person, was about to take his ABFM boards and they fired him, however I am thankful he was not able to inadvertently harm others in independent practice. I believe the residency allowed him to go on so long since they truly wanted to give him every chance possible, even though I do believe they let it go for a bit toooooooo long which I am sure made it more difficult for everyone in the matter when it came time to terminating the individual. Seemed really smart, just couldn't see when patients were about to tank or understand when to de-escalate or escalate care.
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Damn that's really cruel.
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Didn't see it happen in surgery. But what can happen is that people lack the technical proficiency even though they are otherwise a "good doctor". In those situations, I saw a concerted effort by the program to help direct them into a practice setting which would fit.
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Jesus, that's ridiculous. By the time someone reaches 3rd year in our field the program is supposed to be saying "this person is likely to be competent in FM but just needs some polishing to make sure they are set to practice without supervision".
Sounds like this person should have been let go at worst by midway through 2nd year. Letting them take boards and THEN firing them is truly awful.
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I agree, he had a big remediation on inpatient for the first 3-4 months of 2nd year but somehow managed to get by. Still do not know how if he was still deemed incompetent. He was actually let go a week or two prior to his boards. Felt somewhat bad for the guy since I think he should have been told much sooner in his training that he did not have it, but then again the guy used to get under my skin as well during training which made it hard for me to feel too bad for his sake. No program is perfect, ours included (and I still wouldn't have wanted to train anywhere else in the country).
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Most obvious example for non-psychiatrists. Called to evaluate delirious patient in ICU. Recommended 50 mg IV Haldol q6 hours. When attending suggested they perhaps missed out on a decimal point, argued.
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how is that malpractice? That seems reasonable...
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And see I made a decimal error myself there in the original post. Recommendation was for 50 mg IV q6h
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Maybe they just wanted to see what TD looks like first hand
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"I really wanted to try out valbenazine while I was on this rotation, y'know, to get some clinical experience, so I figured, why not kill two birds with one stone?"
oh god..
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Of course the hell of it is, and relevant to this thread, if they had just said 'oh ****, that was totally a mistake, here is how I plan to never let this happen again,' they would have been fine at the end of the day. It was the refusing to admit that they had f'ed up that was the problem.
yeah which goes back to the basic idea, you don’t get fired for incompetence you get fired when you are unteachable likely secondary to your underlying personality structure
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I like how your acronym works twice. I first thought it was an odd way to abbreviate Torsades De pointes, before I realized you meant Tardive Dyskinesia.
Why not both? That way when they code, you'll know you have ROSC when they start aggressively smacking their lips.
EDIT: Ok SDN, fix your idiotic swear filters. This is getting T@rdive.
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If so they would be waiting a long time.... on the other hand acute EPS will definitely be seen. Tardive dyskinesia takes months to years to develop
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I was waiting for someone to call me on this
usually when a trainee is fired it is nothing to do with their medical knowledge. It really boils down to whether the program director or anyone in higher power wants that person out this also translates into a professional environment when you're in attending. I've seen it happen many times and there are certain people who are at risk usually the ones who end up getting terminated or dismissed or whatever term they prefer to use, ends up being some kind of minority and females are targeted more than males. usually the tactic that's approached is to make the physician look as incompetent as possible by giving them terrible reviews and documenting failures.
If you find yourself in this situation a lawyer will never be able to help you and it is essentially a blacklist. It is very difficult to get into other programs once you are terminated. but certainly not impossible.
What usually ends up happening is when a program wants a person out the trainee ends up resigning to have a good recommendation to leave the program on the best terms possible and re-enter training at a lighter point in time unfortunately this is becoming much more common and there are several papers published about this. I've been researching it for a few years because it seems that a lot of trainees are being treated more like employees as opposed to students. And under rules for them as decreed by the national labor relations board, are training templates need to be adjusted. I'm into medical education so it's something that I have observed frequently unfortunately and it seems that most training programs are adopting this approach.
Unfortunately a lot of this involves a power dynamic where the trainees have very little and those in charge such as a program director or chairman or chairwoman has all the cards
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While I'm sure what you describe does happen, I suspect it's very much the minority of terminations.
The 3 people my program fired while I was there were all white men.
In this forum, I have yet to see a case that gets presented where it didn't become obvious once all the details were out there that the termination was not justified.
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Yeah might want to suggest serial EKGs in that case lol . That's ridiculous.......
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I wouldn't take absence of proof as proof of anything.
Residents who actually are not only in a decent position but also smart enough to take advantage of it, get an attorney and take their advice. The ones who have a good case against the administration will be the ones essentially paid for their silence. Usually there is an NDA and the resident will heed it in those cases.
So it's not surprising the cases that you hear about aren't that inspiring. It's the way the selection pressures work.
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Do you have any proof that this happens?
Residency programs are gossip factories. There is an approximately 0% chance that these proceedings occur and escalate to the level of legal action without others in the program knowing about it.
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I have proof it happens and proof that other residents would not know much beyond the simple fact the resident was forced to resign.
They might guess legal action took place, but I would not be surprised if they never had that confirmed by the admin. To my knowledge talking with some of the residents, no one knew. I know the resident never talked to any of the other residents about it because their attorney made that clear. Including friends and family. "Anyone can be made a witness in court."
I mean, is it really so crazy to think that a bunch of doctors would keep their mouths shut because, laws? Isn't that what we do with confidentiality?
If they're on here blabbing about their case, they just aren't that bright, their case isn't very good, they don't have a lawyer or a good settlement with an NDA, or some combination.
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This is probably less incompetence and much more personality disorder.
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Looks like they tweaked it
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I saw! Squeaky wheel gets the grease. This is why I haven't curbed my tendency towards snarky complaints.
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Meh, I realize the poster corrected it to 50 mg q6 (which holy crap!), but even 5 mg q6 IV = 30 mg daily which is a lot of Haldol IV.
this is not outside the standard of care depending on the patient
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I understand. It's still a lot. I never jump to 5 mg q6 with IV.
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Umm... You mean 20mg daily?
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I heard about a patient getting 50 of haldol from an OSH once. Led to a tox consult at our center. I've made some mistakes but tox hasn't had to consult on any of my patients based on the medicines I've given them, so at least I've got that going for me!
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Oops, yes, 20 mg. The point is IV is not equivalent to PO so I still think 5 mg q6H is too much. I usually don't go beyond 2.5 mg IV (which is roughly equivalent to 5 mg PO) when doing q6 dosing or give a higher dose with less frequency. I was trained to do 0.5 mg - 1 mg q2H for IV dosing. My current full time place of employment doesn't allow us to give IV Haldol at all unless patient is on tele and even then it's frowned upon. At my moonlighting gig, they prescribe it in crazy high amounts. Some of the attendings are way more aggressive than I am so YMMV.
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Ugh I hate when you find out bad things that were hidden from you right after you start. My place has never fired anyone over ITE, but they did retroactively say that a good resident should be over 30% after we took the ITE, when before they told us not to worry about it. I don’t like shifting goalposts.
