Former resident in Virginia suing residency program

[maceo]

you're absolutely right---residents need to be unionized. But, it'll never happen, and my guess is that it's because residency is a finite time period. how can union leadership develop when people are residents for only a few years of their career?

This leaves the programs in a position of total power. They hide behind the standard physician martyr arguments, that it's all for the patients, blah blah, but that's not what it's about.

residents are unionized in some locations now..

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Members don't see this ad.

 

[3dtp]

First of all, let's remember that this piece is written from a lawsuit filing. It only displays a highly biased, one sided viewpoint. <snip>

That being said:



Much of the truth regarding this statement will depend on whether the program documented problems in her performance before December.

Agreed. Provided records are not altered. I have seen in counseling a number of similar cases, mysterious letters, papers and documents, some written on scraps of napkin, others elegantly word-processed which were not in copies provided earlier. Much as I would like to assume all programs are honest, I think we know that this is naive.

As others have mentioned, this was done poorly by the PD and, regardless of the PD's intention, could actually sink their case. Here's how this should happen:

A. PD tells resident that their performance is unsatisfactory, asks for resident's opinion.

B. The PD decides if they are concerned about the resident's "fitness for duty". Note that the PD does not decide that the resident is unfit for duty, they simply review the concerns raised and decide whether there is concern.

C. If the PD is concerned the resident is unfit for duty: Then they are 1) removed from all duties effective immediately, 2) referred to another physician, preferably an occ med specialist for evaluation. This evaluation is completely protected from the PD, all they are told is whether the resident is fit for duty, needs accomodations, or is unfit. If the former, then the resident is returned to duty and given full credit for all time (even any time they were pulled). If not, then they cannot return to work until they are cleared by Occ Med.

D. If the PD is not concerned about fitness for duty (or if they were, the resident was tested and passed), then the PD tells resident that an unsatisfactory performance like this, when a resident's prior track record has been otherwise unblemished is often difficult for a resident to understand, process, and address. Situations like this can 1) be caused by underlying psychiatric or social issues, or 2) can trigger psychiatric or social issues. The resident is offered confidential psychiatric assessment. The PD is never told of the outcome of such assessment, or whether it even happened. The resident is told that they will be assessed based on their future performance, but that excuses later that they were depressed, or had a learning disability, will not be acceptable.

The key is to keep both medical and psych evaluations separate from the PD, to make decisions based on resident performance, and to offer support.

Absolutely on point. Again, honest programs, honest directors such as yourself help make the system work. However, sin is loose in the world.

This all looks bad for the PD (again though, we only have half the story). PD's should not require monthly counseling IMHO.

Yet this is precisely what bad programs/malignant programs do, for reasons stated elsewhere.

I am continually amazed to see this is still ongoing. When I was involved in our last ACGME review, I had a long talk with the SV. He told me that the ACGME knows these hours are widely mis-reported in certain programs, that they've done what they can to try to correct the problem and obtain honest reporting, but they are unwilling to take definitive steps against all but the worst offenders. Some years ago, I recommended to the former ED of the ACGME that program citations be made available to residents applying for programs. It was done, but in a general way, with only the fact that there was probation made available.

In a program that has more recently cleaned up its act and dumped a bad PD, in the bad old days, five residents were fired in one year. Two of them were bad choices and terminations were appropriate. The other three? The program director did it because he could and these folks refused to falsify records. And falsifying records includes lying to accrediting agencies on hours worksheets. Or they were otherwise active in attempting to improve working conditions.

It seems like not much has changed in 8 years.

 

[3dtp]

residents are unionized in some locations now..

It will take more than some residents in some locations. It will take all residents everywhere. In 1860, there were abolutionists in some locations in the Union. Slavery did not end because of it.

 

[NotAProgDirector]

It will take more than some residents in some locations. It will take all residents everywhere. In 1860, there were abolutionists in some locations in the Union. Slavery did not end because of it.

To be fair, if a program is well run and treats residents fairly, a union will not help much. If all of the poorly run programs had unions, that might fix the problem.

Except that there are lots of IMG's who never get spots. Let's say I was a jerk, didn't care about the residents in my program, on a power trip. Residents decide to unionize. Come to me, demand to be treated fairly. What do I do?

I fire all of them, and hire new IMG residents who didn't get spots before.

This assumes I'm willing to do so -- presumably the new residents I get won't be as good as the ones I had.

Also, it assumes that all residents at an institution are willing to band together. In general, most residents are hired by the GME office not the individual programs. Thus, the union will be all residents. If the GS residents hate their program but the IM residents are happy, I don't know if the GS program alone can go on strike, or if the IM residents would need to strike with them (and if they would be willing to)

 

[DrJosephKim]

This is a fascinating case. I'm eager to see how everything turns out. Of course, when things are reported by the media, you never really know what to believe.

 

[Trifling Jester]

Except that there are lots of IMG's who never get spots. Let's say I was a jerk, didn't care about the residents in my program, on a power trip. Residents decide to unionize. Come to me, demand to be treated fairly. What do I do?

I fire all of them, and hire new IMG residents who didn't get spots before.

It is my understanding that reimbursement for IMG's is less than for AMG's (reimbursement to the hospital/training program, not the individual physician).

-The Trifling Jester

 

[exPCM]

It is my understanding that reimbursement for IMG's is less than for AMG's (reimbursement to the hospital/training program, not the individual physician).

-The Trifling Jester

Trifling Jester,
Your statement is 100% incorrect. The funding is identical.
http://www.amsa.org/pdf/Medicare_GME.pdf

 

[Apollyon]

It is my understanding that reimbursement for IMG's is less than for AMG's (reimbursement to the hospital/training program, not the individual physician).

-The Trifling Jester

Although not to jab at one person or another, that statement is not "100%" incorrect, but needs some explanation. There are monies for "Direct Medical Education" and "Indirect Medical Education" (DME and IME). The IME funding is paid for IMGs, and is 50% of DME. HOWEVER, this way and that, the IMG money will still come, and it comes out to 100% in the end.

No offense to aPD, but a lot of program directors and GME people are money-grubbers, and not good at it (a used-car salesman and an attorney are much better). When I was at Duke, they touted that the provided malpractice insurance for residents as a perk (actually as a benefit)- even though that is a requirement of the ACGME - and, if it's required, it's not a perk.

 

[NotAProgDirector]

Although not to jab at one person or another, that statement is not "100%" incorrect, but needs some explanation. There are monies for "Direct Medical Education" and "Indirect Medical Education" (DME and IME). The IME funding is paid for IMGs, and is 50% of DME. HOWEVER, this way and that, the IMG money will still come, and it comes out to 100% in the end.

AFAIK, IMG's get 100% DME just like everybody else during their residency. All fellows, regardless of AMG/IMG, are reimbursed 50% DME.

 

[exPCM]

Although not to jab at one person or another, that statement is not "100%" incorrect, but needs some explanation. There are monies for "Direct Medical Education" and "Indirect Medical Education" (DME and IME). The IME funding is paid for IMGs, and is 50% of DME. HOWEVER, this way and that, the IMG money will still come, and it comes out to 100% in the end.

No offense to aPD, but a lot of program directors and GME people are money-grubbers, and not good at it (a used-car salesman and an attorney are much better). When I was at Duke, they touted that the provided malpractice insurance for residents as a perk (actually as a benefit)- even though that is a requirement of the ACGME - and, if it's required, it's not a perk.

Although not to jab anyone either, you are wrong and apd is correct regarding GME funding of IMGs.

 

[Apollyon]

Although not to jab anyone either, you are wrong and apd is correct regarding GME funding of IMGs.

Do you feel better now, pointing that out, that I was wrong, even though, in the post above yours, that aPD mentioned this? There is a reason I am being verbose in mentioning I was wrong - do you feel better? I was wrong.

Then again, with your post, and the prior "100%", I think I see a pattern of absolutism.

Did I tell you that I was wrong? I was wrong. Oh, and, by the way, I was wrong.

That which I may have been thinking was the reimbursement for time after the "medicare clock" runs out. That was the 50%/100%. I can assure you, despite my being wrong, my program director never told me that the monies for my training were 1/2 as much as someone else's, as I'm an FMG.

 

[exPCM]

Do you feel better now, pointing that out, that I was wrong, even though, in the post above yours, that aPD mentioned this? There is a reason I am being verbose in mentioning I was wrong - do you feel better? I was wrong.

Then again, with your post, and the prior "100%", I think I see a pattern of absolutism.

Did I tell you that I was wrong? I was wrong. Oh, and, by the way, I was wrong.

That which I may have been thinking was the reimbursement for time after the "medicare clock" runs out. That was the 50%/100%. I can assure you, despite my being wrong, my program director never told me that the monies for my training were 1/2 as much as someone else's, as I'm an FMG.

My are we sensitive now. 1st you post that I am incorrect in my response to Trifling Jester. Then when I defend my post you get bent out of shape and seem to be implying you got the incorrect information from your program director.
Two points come to mind:
1. It is a good idea to learn to research topics on your own.
2. Do not post on a public board criticizing someone else before doing #1.

If you do those 2 steps it is much less likely that you will have to post later that you were wrong.

Alternatively you could have posted "Hey exPCM are you sure about your response to Trifling Jester? My pd told me something different." But instead you chose to post heresay as fact and now seem to get irritated when I call you on it.

 

[Apollyon]

No, it's not me. It's you. You, first, didn't have to say "100% incorrect". You started that. Then, you added an unnecessary post to point out, redundantly, that I was wrong. That's why I had the absurd post after that. You don't seem to get that. It's not sensitive - it's absurdity. And, even as I stated my error, and from where I believe I was coming, you still offer me "advice", even though, before your "advice", I'd clarified.

So, give it up. And do not go to excess to criticize someone else on a public board, posting things like:

Trifling Jester,
Your statement is 100% incorrect. The funding is identical.

You could have posted something like "Hey Trifling Jester, it's paid equally - here's a link." But YOU didn't.

So, YOU started out with a prick move like "100% incorrect". That's what tripped it off. And since you decided at 8am on Sunday morning to rebut, that says something about you (as a hint, it's 11am HST right now - I don't post at 8am Sunday, even if I AM awake).

 

[exPCM]

No, it's not me. It's you. You, first, didn't have to say "100% incorrect". You started that. Then, you added an unnecessary post to point out, redundantly, that I was wrong. That's why I had the absurd post after that. You don't seem to get that. It's not sensitive - it's absurdity. And, even as I stated my error, and from where I believe I was coming, you still offer me "advice", even though, before your "advice", I'd clarified.

So, give it up. And do not go to excess to criticize someone else on a public board, posting things like:



You could have posted something like "Hey Trifling Jester, it's paid equally - here's a link." But YOU didn't.

So, YOU started out with a prick move like "100% incorrect". That's what tripped it off. And since you decided at 8am on Sunday morning to rebut, that says something about you (as a hint, it's 11am HST right now - I don't post at 8am Sunday, even if I AM awake).

Actually I did post a link. The statement I said was 100% incorrect was in fact 100% incorrect. If you can't handle the truth that is your problem not mine. The statement "100% incorrect" is not what I would call profane.

I post on Sunday and a lot of doctors round on Sunday. We don't get every Sunday off as physicians in general.

It is obvious that they didn't teach you proper etiquette at your foreign medical school. Hopefully you don't act this way when treating patients.

 

[NotAProgDirector]

Folks -- let's try to remain civil here. Sept 1 is around the corner, and everyone is feeling the pressure. We are all here to learn.

 

[Apollyon]

I was backing someone else up. Step I is long gone for me (as is Step II, and Step III).

And the former military doc invokes Burnett's Law - yeah!

 

[Trifling Jester]

Although not to jab at one person or another, that statement is not "100%" incorrect, but needs some explanation. There are monies for "Direct Medical Education" and "Indirect Medical Education" (DME and IME). The IME funding is paid for IMGs, and is 50% of DME. HOWEVER, this way and that, the IMG money will still come, and it comes out to 100% in the end.

What I had heard was that FMG's do not count as a complete FTE, they count as less than that. I have not been able to confirm this online.

-The Trifling Jester

 

[Apollyon]

What I had heard was that FMG's do not count as a complete FTE, they count as less than that. I have not been able to confirm this online.

-The Trifling Jester

Watch out - you might be told that you are "100% wrong". (The "100%" being an unnecessary modifier.) Good manners are always good policy.

And I think it was clarified that, for a first residency, all are 1.0 FTEs. It's for additional training after the clock has run out that is 0.5, but, as to which I clumsily alluded, if one does a fellowship or another residency, the program will still get the money, just not directly. But no one works for free.

 

[razorback58]

The real question is how do you violate work hours in family medicine?

I have worked 30 days straight as an intern and broke the 80 hour rule.
I am FP.
I have been subjected to similar treatment.
I have exceeded the 80 hour rule by at least 20 to 25 hours.
We got a memo our first year of residency that said there were "mistakes" made on the last eval and this is how the evaluation should be filled out - we were exceeding the 80 hour limit at the time. Our evaluations are not confidential either.

No due process in residency - only the court system. ACGME does not care. The hospital does not care.

When we filled it out truthfully the second year, the PD was upset. We told him about the problems prior to the eval and he did nothing to change it. He finally did some modification after the eval. but he has a way of knowing who did what on the eval.

I have some scary stories about myself in this situation.

I hope she wins.

 

[doctorsherlock]

One battle at a time.

Serrano. Nigro. Who next?

Program Directors. Yes. You.

With every precedent, your hegemony cracks.

So let the casualties fall. Let the fertile soil pile up. Let the lawyers plant more seeds for a blooming cottage industry.

These are times of scarcity. The incentives are high.

These are times of honesty. The truth flows free.

 

[voitokas]

Only solution would be for residents to unionize. If one gets penalized for whistleblowing, other residents apply repurcussions to the program, such as cutting hours from 80 to 75. Work won't get done, so attendings will have to do it or program continues penalizing, leading to a downward spiral. In the end, patients will suffer and the program will look idiotic.

The only way in the absence of a governing body....

 

[RegularNihilist]

To be fair, if a program is well run and treats residents fairly, a union will not help much. If all of the poorly run programs had unions, that might fix the problem.

Except that there are lots of IMG's who never get spots. Let's say I was a jerk, didn't care about the residents in my program, on a power trip. Residents decide to unionize. Come to me, demand to be treated fairly. What do I do?

I fire all of them, and hire new IMG residents who didn't get spots before.

Which is why doctors would be better off losing the protectionist system, and removing the need for post-graduation training in order to practice medicine as a specialist. No need to beg for a residency spot equals power change.

 

[NotAProgDirector]

Which is why doctors would be better off losing the protectionist system, and removing the need for post-graduation training in order to practice medicine as a specialist. No need to beg for a residency spot equals power change.

... except that medical students graduating from school are completely incompetent to practice medicine, and need some form of further training.

It's a very complicated situation. PD's are charged with running residency programs, overseeing the training of residents, and certifying whether they have mastered the skills necessary to practice independently. They need the ability to prevent incompetent residents from graduating. Problem is, there is no agreed upon definition of "competent" nor any objective way to measure it, and there will never be one.

The core of the problem is that residents have always been seen as the workhorses that get the work of the hospital done 24/7. If hospitals actually staffed themselves fully and then added residents on top of that, many of these problems would go away. But doing so would be very expensive, and would further bankrupt medicine in general.

Unfortunately, the system allows PD's and hospital systems to abuse residents without any effective check-and-balance.

 

[exPCM]

... except that medical students graduating from school are completely incompetent to practice medicine, and need some form of further training.

It's a very complicated situation. PD's are charged with running residency programs, overseeing the training of residents, and certifying whether they have mastered the skills necessary to practice independently. They need the ability to prevent incompetent residents from graduating. Problem is, there is no agreed upon definition of "competent" nor any objective way to measure it, and there will never be one.

The core of the problem is that residents have always been seen as the workhorses that get the work of the hospital done 24/7. If hospitals actually staffed themselves fully and then added residents on top of that, many of these problems would go away. But doing so would be very expensive, and would further bankrupt medicine in general.

Unfortunately, the system allows PD's and hospital systems to abuse residents without any effective check-and-balance.

I usually agree with your posts but completely disagree with your statement that med students are incompetent to practice medicine. I have worked with and precepted both PA and medical students and a PA student can go straight to work in a Minute Clinic after graduation without any direct supervision on site. I can vouch for the fact that the graduating med students are certainly no less competent than the graduating PA students. http://www.minuteclinic.com/careers/job-9610.aspx

 

[dragonfly99]

exPCM
that's a ridiculous argument.
Treating people who are not very ill at all (Minute Clinic patients) using some flowchart and under supervision of a doctor is very different than treating actual sick patients.
We tried a relatively unregulated system of medical training (before Flexner Report) where I think people just apprenticed themselves out, and started practicing whenver they felt it was OK to do so. That didn't work well.

 

[exPCM]

exPCM
that's a ridiculous argument.
Treating people who are not very ill at all (Minute Clinic patients) using some flowchart and under supervision of a doctor is very different than treating actual sick patients.
We tried a relatively unregulated system of medical training (before Flexner Report) where I think people just apprenticed themselves out, and started practicing whenver they felt it was OK to do so. That didn't work well.

Actually you are being quite naive. If you think patients who are sick do not go to Minute Clinics you are sadly mistaken. There are people who are having MIs who think it is indigestion and will show up at a Minute Clinic or other primary care setting instead of calling 911. I am quite familiar with the Flexner Report. With the explosion of new midlevel programs with rubber stamp accreditation you might argue that medical training is already becoming quite variable in quality/quantity.

Then of course you have Carribean schools and schools like Rocky Vista which are IMO more interested in making money than education anyway. These schools just farm out their students in the 3rd and 4th years to widely dispersed clinical settings that vary tremendously in the caliber of student education. Do you think that these schools really do any serious quality control in establishing clinical rotations?. A primary factor is how much does the school have to pay the clinical site to take the student. The less money the school has to pay the clinical site the greater the profit for the school. SGU paid 100 million for 600 clerkship positions per year for their students for 10 years to NY HHC and SGU will still make a nice profit http://www.sgu.edu/news-events/news-archives07-HHC.html . (This roughly calculates to 100 million/120 months/600 students = $1388 per student per month - tuition at SGU in the clincal years works out to ~50K/year or about $4200 per month).
I have heard that VCOM (in the same state as the resident filing suit in this thread) pays $1000 per student per month to the clinical rotation sites ( http://www.guidestar.org/FinDocuments/2008/542/052/2008-542052107-04bebe3e-9.pdf ) .
Look at statement 5 and you will see that VCOM paid Carillion $133,000, UMDNJ $122,000, and Salisbury VA $113,000 for precepting students. Tell me how you know that the caliber of training at these sites is all equal.
Where I went to med school in TX and where I have practiced in CA I have had med school faculty tell me that they pay lower rates to clinical sites and there are numerous sites which will take 3rd and 4th year students in limited numbers for free (often they are sites connected with residency programs for which the student rotations help them in recruiting for residency). There are also quite a few private practice docs who will still volunteer to take students at their offices for free but that number is dwindling as many docs are working harder to keep their practices afloat as reimbursements decrease and they really don't have time for teaching.
Here is a group that charges IMGs 300-400 per week for clinical training - What do you think they pay the training sites and what is the caliber of training? http://www.gmcgroup.org/tuition.html
Do you think Flexner would like this?
I do not know how much Rocky Vista will pay but I am sure they will be interested in getting a lower price rather than a higher one. If they are willing to pay $2000 per student per month than they can probably get the Mayo Clinic to take their students. If they are willing to pay $200 per student per month then it is probably Boondocks Hospitals in Green Acres, Colorado.
The education that the student receives in medical schools now is widely variable in the 3rd and 4th year at many US medical schools.
Also if you think that PAs and NPs are really supervised in the vast majority of settings you are dreaming. What happens is that after the fact some percentage of charts are being reviewed. The chart may or may not be an accurate description of the patient encounter. I have seen buffed charts where questions are documented that the patients were not asked and exam findings documented that were not perfromed.
So in a nutshell there are really IMO only two reasonable positions:
1. Both PA grads and med school grads are competent to practice medicine.
2. Both PA grads and med school grads are incompetent to practice medicine.

If your position is number 1 or 2 then I won't argue. However any position that states that PA grads are competent and med school grads are incompetent is to me ridiculous and hypocrticial.

 

[pgg]

2. Both PA grads and med school grads are incompetent to practice medicine.

The military has this phenomenon called a "General Medical Officer" ...

People who finish medical school funded by the military have some period of obligated service. What happens frequently is that the person completes an internship and then before completing a residency they are assigned to an operational unit as their primary care physician. I went to a Marine infantry battalion before returning to an anesthesiology residency.

There is essentially no supervision of these physicians and they practice independently ... even in states that require >1 year of postgraduate training to issue a medical license. (They simply get licensed in another state because you can practice at any government facility with a current license from any state.)

Even the military, which

• has by FAR the healthiest patient population of any organization
• is cheap, stingy, undermanned and always looking to save a buck
• enjoys incredible legal insulation and is all but immune to malpractice claims from active duty members

has acknowledged that a GMO is undertrained and those positions are being (slowly) converted to board eligible/certified physicians.

As someone who practiced in a primary care environment after just my PGY1 year, and feels fortunate to have escaped without harming anyone or missing anything big, I find your assertion that it's safe to unleash a brand new physician (without a PGY1 year no less!) on the world is just comically insane.

 

[exPCM]

The military has this phenomenon called a "General Medical Officer" ...

People who finish medical school funded by the military have some period of obligated service. What happens frequently is that the person completes an internship and then before completing a residency they are assigned to an operational unit as their primary care physician. I went to a Marine infantry battalion before returning to an anesthesiology residency.

There is essentially no supervision of these physicians and they practice independently ... even in states that require >1 year of postgraduate training to issue a medical license. (They simply get licensed in another state because you can practice at any government facility with a current license from any state.)

Even the military, which

• has by FAR the healthiest patient population of any organization
• is cheap, stingy, undermanned and always looking to save a buck
• enjoys incredible legal insulation and is all but immune to malpractice claims from active duty members

has acknowledged that a GMO is undertrained and those positions are being (slowly) converted to board eligible/certified physicians.

As someone who practiced in a primary care environment after just my PGY1 year, and feels fortunate to have escaped without harming anyone or missing anything big, I find your assertion that it's safe to unleash a brand new physician (without a PGY1 year no less!) on the world is just comically insane.

Actually you are wrong - this is NOT MY ASSERTION but it is the assertion of almost all state licensing boards in the country who are allowing PAs to practice fresh out of schools that generally last an average of 26 months with only 50 weeks of clinical training ( http://www.careercenter.uiuc.edu/health/prof/pa.asp ) as opposed to 4 years of medical school. I generally must assume that all these learned folks on these state boards can't be wrong or can they?
Or how about nurse practitioners who can practice independently in many states and often have less training than PAs ( example: http://www.montana.edu/wwwnu/pdf/grad/FNP2yearProgramofStudy.pdf )
Therefore if PAs and NPs are deemed competent than by default graduating med students are competent.
If you want to argue that both PAs/NPs just out of school and med students just out of school are both incompetent then take your objections to your state licensing boards and the Minute Clinics but not to me.
P.S. FYI - up until the 1970s the majority of docs did a 1 year internship and went out into practice just like the GMOs do today. One difference then is that medical students had a more active education in the clinical years than today. I have heard that many hospitals now do not let med students write any notes, orders, or H&P's in the chart and thus the learning experience is now more passive than active.

 

[Magnus2010]

That is an interesting case. Lets say someone had evidence to substantiate claims of harrassment from an attending or pressure to lie about work hour violations - like emails from several other residents back and forth etc - ?

What sort of lawyer would handle this case? I can't imagine it would just be a typical labor relations lawyer as this is a highly specialized case.

 

[pgg]

Actually you are wrong - this is NOT MY ASSERTION but it is the assertion of almost all state licensing boards in the country who are allowing PAs to practice fresh out of schools

When they graduate, they're qualified to practice under the supervision of a physician ... just as a new medical school graduate is qualified to practice under the supervision of a physician.

Neither is qualified to head off and go it alone.

P.S. FYI - up until the 1970s the majority of docs did a 1 year internship and went out into practice just like the GMOs do today.

Yeah, and a couple centuries ago barbers performed surgery. If you want to put your first name in the book at a Hair Cuttery front desk when you need your appy, more power to you, but the world isn't what it once was.

This isn't the 1970s, medical school isn't what it once was (as you acknowledged), and a guy who graduated medical school yesterday simply isn't qualified to work on his own.

 

[exPCM]

When they graduate, they're qualified to practice under the supervision of a physician ... just as a new medical school graduate is qualified to practice under the supervision of a physician.

Neither is qualified to head off and go it alone.

If you think that PAs/NPs are closely supervised then go to any Minute Clinic and ask to see the supervising physician. You will find that there is typically no on site supervising physician. The whole system of supervision of PAs/NPs is highly variable from what I have seen. In many states NPs can practice independently anyway.

Yeah, and a couple centuries ago barbers performed surgery. If you want to put your first name in the book at a Hair Cuttery front desk when you need your appy, more power to you, but the world isn't what it once was.

This isn't the 1970s, medical school isn't what it once was (as you acknowledged), and a guy who graduated medical school yesterday simply isn't qualified to work on his own.

Yes the world is not what it once was.
Once upon a time only physicians practiced medicine. Now we have an explosion of NPs/PAs/ODs/CRNAs/Naturopaths, etc. practicing medicine often with no supervision or little supervision.
What about all the states that license and allow independent practice of naturopathic physicians? http://www.oregonlive.com/health/index.ssf/2009/06/what_the_latest_legislation_on.html
Do you consider a graduating naturopath better trained than a graduating med student?
I sense a huge disconnect from how you want things to be and how they really are.

 

[pgg]

I sense a huge disconnect from how you want things to be and how they really are.

Again - I was a GMO with the Marines after a year of internship training. I had backup help available about 90% of the time. The remaining 10% when I was truly on my own was tense.

I'm finished with residency now. Looking back, I can see a number of things I did that were stupid, risky, and simply below an acceptable standard of care. It's not that I was a ****** or cowboy, I just didn't know any better.

I also see some of what current GMOs who have only the benefit of an internship do. It's all indirect because I'm an anesthesiologist, but I frequently hear surgeons say "you wouldn't believe what that flight surgeon sent to my clinic this morning" ...

Say what you want about the way the real world works; I believe you when you say that fresh physician "assistant" grads are working totally unsupervised. I also believe that there is probably a lot of marginal care, inappropriate testing, unnecessary referring, and just plain substandard work out there.

If you're OK with that or think it's an acceptable compromise for lower cost care, fine; just don't pretend that the lack of supervision new PAs have is a fantabulously wonderfully peachy state of affairs or an argument that new MDs are competent PCMs on postgraduate day 1.

 

[exPCM]

Again - I was a GMO with the Marines after a year of internship training. I had backup help available about 90% of the time. The remaining 10% when I was truly on my own was tense.

I'm finished with residency now. Looking back, I can see a number of things I did that were stupid, risky, and simply below an acceptable standard of care. It's not that I was a ****** or cowboy, I just didn't know any better.

I also see some of what current GMOs who have only the benefit of an internship do. It's all indirect because I'm an anesthesiologist, but I frequently hear surgeons say "you wouldn't believe what that flight surgeon sent to my clinic this morning" ...

Say what you want about the way the real world works; I believe you when you say that fresh physician "assistant" grads are working totally unsupervised. I also believe that there is probably a lot of marginal care, inappropriate testing, unnecessary referring, and just plain substandard work out there.

If you're OK with that or think it's an acceptable compromise for lower cost care, fine; just don't pretend that the lack of supervision new PAs have is a fantabulously wonderfully peachy state of affairs or an argument that new MDs are competent PCMs on postgraduate day 1.

I do not think having these unsupervised new grads is a positive development but it is not my call and I guess it's just the way it is these days.
However it really frosts me to say that med students are incompetent if we are going to say that lesser trained new grad PAs/NPs/naturopaths are competent. That is a complete double standard IMO.

 

[RegularNihilist]

As someone who practiced in a primary care environment after just my PGY1 year, and feels fortunate to have escaped without harming anyone or missing anything big, I find your assertion that it's safe to unleash a brand new physician (without a PGY1 year no less!) on the world is just comically insane.

Germany has abolished the PGY-1 year, and for some years now, doctors are allowed to practice medicine straight outta med school. Their practical training resembles what US physicians go through on their rotations, the last german year consists of rotations where you work in hospital under supervision.

... except that medical students graduating from school are completely incompetent to practice medicine, and need some form of further training.

OK.

How come hospitals cannot give this further training to postgrads, unless they are in an inferior position legally, and forced to work for nil money? How come this training can't come as a result of just working, like you do in residency?

 

[NotAProgDirector]

How come hospitals cannot give this further training to postgrads, unless they are in an inferior position legally, and forced to work for nil money? How come this training can't come as a result of just working, like you do in residency?

Not quite sure what you are asking. Residency is working in a hospital, under supervision. Residents are paid for this. I think we agree that residents are underpaid, and you have no argument from me that they should be paid more.

Should any hospital be allowed to hire a recent MD grad and train them? With no supervision?

If I treated my residents purely like employees -- I'd get rid of most conferences, all electives, etc. You'd just come to work, and work. Probably work less and get paid more, but I'd get rid of the rest of the education.

And how would we know when you were ready for independent practice? Do I just get to say so? And is that any better than where we are now? You could end up like the UK system, where some docs get stuck at the RMO level permanently.

 

[RegularNihilist]

Not quite sure what you are asking. Residency is working in a hospital, under supervision. Residents are paid for this. I think we agree that residents are underpaid, and you have no argument from me that they should be paid more.

Should any hospital be allowed to hire a recent MD grad and train them? With no supervision?

If I treated my residents purely like employees -- I'd get rid of most conferences, all electives, etc. You'd just come to work, and work. Probably work less and get paid more, but I'd get rid of the rest of the education.

And how would we know when you were ready for independent practice? Do I just get to say so? And is that any better than where we are now? You could end up like the UK system, where some docs get stuck at the RMO level permanently.

Yep, any hospital should be allowed to hire ANY MD grad, with no supervision. Free market. If the training I got at your place didn't do jack to give me e.g surgical skills, I would go somewhere else.

If there were no restrictions on where you could work, there wouldn't be anything stopping US residents from spending 2 years learning a language, instead of taking BS classes as a pre-med, and then train in a country where medical education is cheap. There will always be someone willing to hire a foreign trained doc, maybe not as attractive as a US grad, but that only translates into cheaper workforce. From the doctors point of view, there will always be some hospital accepting you.

See, that is the problem in US medicine (for students, pre-meds, patients who want maximum health outta their money, or who can't afford health, and foreign docs), and it is self-perpetuating. The protectionist stand that residency is required in order to practice, ensures that hospitals and expensive universities get the upper hand. And this translates into high tuition costs, which again, ensures political support for a protectionist system, so mexican docs won't flood the borders. If US grads didn't have to train in the US to work there, in the first place, med students could take full advantage of global medicine/global learning and have the prices drop.

 

[NotAProgDirector]

Yep, any hospital should be allowed to hire ANY MD grad, with no supervision. Free market. If the training I got at your place didn't do jack to give me e.g surgical skills, I would go somewhere else.

If I hire you, with no supervision, then there isn't any training. I'm just hiring you to do a job. Given what people learn in medical school (in the US) I find this terrifying. Why should I hire new MD's? They can't work on their own, they don't know enough to be safe yet. Should I just let them make mistakes to learn?

Perhaps what you are suggesting is the apprenticeship model -- you are free to attach yourself to anyone you want to learn medicine. We dropped this as a model many years ago due to multiple abuses and very poor quality control.

Perhaps you are suggesting that medical school should be changed so that people emerge with more skills. Make internship part of medical school, and shorten it by a year. Or, make it 5 years with an internship. Problem is that most medical schools couldn't handle all of their students as interns, esp in some of the smaller fields.

If there were no restrictions on where you could work, there wouldn't be anything stopping US residents from spending 2 years learning a language, instead of taking BS classes as a pre-med, and then train in a country where medical education is cheap. There will always be someone willing to hire a foreign trained doc, maybe not as attractive as a US grad, but that only translates into cheaper workforce. From the doctors point of view, there will always be some hospital accepting you.

Why have medical school at all then? Why not just let anyone who wants to be a doctor be hired by a hospital and learn as they go?

See, that is the problem in US medicine (for students, pre-meds, patients who want maximum health outta their money, or who can't afford health, and foreign docs), and it is self-perpetuating. The protectionist stand that residency is required in order to practice, ensures that hospitals and expensive universities get the upper hand. And this translates into high tuition costs, which again, ensures political support for a protectionist system, so mexican docs won't flood the borders. If US grads didn't have to train in the US to work there, in the first place, med students could take full advantage of global medicine/global learning and have the prices drop.

I'm lost again. The cost for medical students is mainly medical school, not residency. If you're suggesting that medical school tuition is ridiculously high, I completely agree. If you're suggesting that we should just let anyone from any other country who has an MD (or equivlanet) and presumed training practice in the US, that's crazy. There would be no quality control. And the USMLE's are not quality control.

The crux of your argument seems to be that we could make healthcare much cheaper if only we outsourced it to foreign medical schools which are "cheaper", but probably are only so because they are subsidized by their home governments. This seems about as foolish as outsourcing our energy needs to unstable, unfriendly countries half way around the world, or fueling our entire economy on unsustainable consumer and government debt, or exporting all of our manufacturing jobs to countries with lower wages/standards of living because it makes things cheaper for us but forgetting that this will cause many of these jobs to disappear in the US leaving a large part of our workforce unemployed. But those things are so foolish that no one in their right mind would do them.

 

[DarthNeurology]

If I hire you, with no supervision, then there isn't any training. I'm just hiring you to do a job. Given what people learn in medical school (in the US) I find this terrifying. Why should I hire new MD's? They can't work on their own, they don't know enough to be safe yet. Should I just let them make mistakes to learn?

Perhaps what you are suggesting is the apprenticeship model -- you are free to attach yourself to anyone you want to learn medicine.

The problem with U.S. medical schools, IMHO, is that the third and fourth year clerkships are spent by medical students doing a lot of busy work, like clerical type working, i.e. getting vitals on patients and not learning medicine. While U.S. med schools supposedly offer some of the best education this is a fallacy as it is more the students who are selected, and not any educational commitment on the part of faculty. You can go to a carib school, get stellar clinical scores and if you study and work hard in clinicals you come ahead of the majority of U.S. students.

I think that the first two years of med school, i.e. basic sciences should have tuition, however, the third through fourth (or I propose fifth year) should have little tuition as students are taking over the role of lazy nurses and lack of residents. There are tons of med students who graduate and don't know what to do in simple situations, this is why intern years is so hard for many and why many fail out of residency. If med school was expanded to three years clinical work with increasing responsiblity it would bettter than the current situation

 

[RxnMan]

...You can go to a carib school, get stellar clinical scores and if you study and work hard in clinicals you come ahead of the majority of U.S. students...

If you get stellar scores and if you study and work hard, you'll probably be ahead of the majority of your peers, no matter what field you're in or the nation the school is in. This is common sense.

...There are tons of med students who graduate and don't know what to do in simple situations, this is why intern years is so hard for many and why many fail out of residency...

By the same token, one could say that we need better educators. I don't believe the 2+2 model is the best anymore, either - Duke for one is making a huge grab for all of the year-out programs and securing a spot as the source of future physician-scientists. Penn's program supposedly has some of the best Step I scores out there.

 

[RegularNihilist]

Why have medical school at all then? Why not just let anyone who wants to be a doctor be hired by a hospital and learn as they go?

I don't know? Why not just let anyone who wants to work that way, do it?

Onto your other concerns:

First of all, who knows how you and other employers will find your employees in the future.

Who knows what institutions will produce the best doctors.

My guess is, that in a completely liberalized system, modes of education would emerge, that would be favored by the employers. Now, if you wanna go with the old apprentice model, be my guest. Others might prefer to hire those who have attended med schools, those having passed certification exams in other countries, those having certificates that they have attended physical exam classes, etc.

There would be no quality control. And the USMLE's are not quality control.

Supporting the existing quality control, is like forcing everybody to pay for the same insurance. The consequences of quality control directly affects the availability of cheap medicine. The forced quality control in the US model, is keeping supply of doctors down, because there are a limited amount of residencies, prog.dirs can be picky, and this keeps the market from being flooded with cheap mexican and east european doctors.

The employers and the patients could very well do quality control, according to what quality control they find worthy of the price tag. It would be up to you to run background checks on new employees, their training, and their fit into your organization.

It is easy to see how new technology can increase transparency, and make it easier for the general public to estimate the quality of the doctors in question, their popularity, their controversies, etc. If you want government-guided control, have the government do a ranking list of doctors and customer health and make it public.

You act on the assumption that we all ought to support a god-given quality control, due to a natural obligation to prevent doctors from seeing patients unless they reach an arbitrarily quantifiable score, and pass a selection based on vague personality criteria during residency. That is just your preference, or your cynical best interests, but has nothing to do with craziness and morality. That is just BS argumentation, and you are intelligent enough to know it.

The honest argument is that current doctors would not benefit from this. Most patients would. Students wanting to become doctors, who can't afford it, would benefit. It is a conflict of interests.

 

[RegularNihilist]

By the same token, one could say that we need better educators.

It's not just about changing the mode of being told and shown things. Becoming independent as a doctor has a lot to do with gradual introduction to responsibility. Getting big responsibility is a huge motivator to learn what you need to learn, and having someone behind your back, is a huge security net to insure that you don't f-ck up. Both could be provided by an employer. Combined education-work. The hospitals providing the best combination here, would be the ones winning in the long run.

 

[snowbank]

OK guys,

I just stumbled upon this thread. And its so long with so many excellent points (some that I was emphatically shaking my head to) and others shaking the other way - that I even forgot which ones I liked (the ramble discussion near the end didn't help much either). While that in itself is a huge discussion - and should have a separate devoted to it - I am much more interested in the outcome of the actual lawsuit on which this thread is based. Whatever happened to the poor resident - did she find a position elsewhere?

And like some of the other posters here - this thread strikes close to home. I am fortunate (LOL!) read so daaaa$n UNfortunate - to have seen 2 malignant programs..that fire people every year...

 

[Bobblehead]

http://docs.justia.com/cases/federal/district-courts/virginia/vawdce/5:2009cv00064/74291/68/

Count descriptions on page 5-6, partial dismissals on pages 30-31. Some counts will continue including public defamation, gender discrimination, retaliation. Since this opinion was offered on 6/4/10 I have a feeling this case won't be resolved for years. As usual the deeper pockets will try to outlast the case.

 

[JerryMeister]

I know about this program and the PD, most of the attendings and the program as a whole SUCKS. So if this is all true I hope:

1. She gets her pound of flesh...directly from the PD.

2. The entire program is driven into the ground with a wrecking ball and after it's torn down a hot dog stand is built on it.

3. The PD and attendings involved are out there with cardboard signs, fingerless gloves, and a junkyard dog begging on the streets, raiding garbage dumps and living in large appliance boxes.

Since we all know that malignant programs are out there, does anyone know of a compiled list of these and where this can be found?

 

[Roofie]

The line of reasoning is typical for a non-renewal case. The classification of the resident as a student allows this. But residency has both academic and employment issues. A contract that states that the residency is primarily academic does not necessarily make it so. Just like a contract that says the sky is green does not necessarily make it true. In law, these things can sometimes happen.

In what traditionally academic environment can a student with reasonable grades be expelled for an academic reason? Students expelled from school are dispelled for a stated and truthful reason, like violating a school's conduct policy. The school respects the student's dignitary interest. In residency, a traditionally academically competent resident can still be expelled for an academic deficiency, where academic deficiency is defined more broadly to include traditionally conduct issues. There is no respect of the dignitary interest here. The court just glosses over that issue when it analogized other dignitary interest cases.

How many schools exist that require students to sign contracts that require them to work seventy hours for the twelve hours of lectures that they get in addition to the study time required for those twelve hours? None. I do not recall signing a thirty page contract upon entering university or medical school. Residency is not completely academic. It is the legal classification that residency is completely academic that undermines the substantive rights of residents. The case law completely ignores the actual facts on the ground that suggest that residency has significant employment issues; and subsequently, all of its inherent biases and arbitrariness that do not occur in similar frequency in a traditional academic environment.

Likewise, the court says that the resident could continue her training elsewhere. But it did not analyze the probability that its assertion was true. Also, it did not analyze the damages she would suffer, like whether she would have to repeat the year or go to a different field. The court did not assess whether the institution of medicine would discriminate against similar residents in her situation.

Currently, the policies that support these decisions need to be re-balanced with a more thorough understanding of what residency training is. The current case law perpetrates an injustice. The resident in this case only had a case because she could claim federal protection under the Civil Rights Act of 1964. A white male resident would have just gotten the shaft.

Residents need attorneys with their interests at heart who can devote the effort to getting these lines of cases overturned. The attorneys need to pierce the medical system's aura of righteousness and benevolence. The system works fine; but when it breaks down, the law offers little justice. If the plaintiff's allegations are true, then the program directors, by law, did nothing wrong or were immune from suit for their conduct on most of the claims. The law basically allowed the program directors to abuse their discretion and trust by framing a competent resident for asserting her rights under ACGME policies.

Regardless of what the law says, the allegations, if proven true, call into question the integrity of the program directors. Medicine's integrity is certainly diminished when it supports such conduct. Professional self-regulation has historically been used in such cases. But times have changed. Residents now assert diverse interests that call into question the efficacy of self-regulation, especially when the tortfeasors function as the regulators.

Judges need to understand that physicians are not lawyers and that they are fully capable of misconduct in an academic context, often times without knowledge of the legal ramifications of their actions.

 

[JimT30]

http://docs.justia.com/cases/federal/district-courts/virginia/vawdce/5:2009cv00064/74291/68/

A lot of this case was dismissed, but there is still a substantial part remaining

 

[slight365]

Dismissal of portions of the case should not be seen as anything out of the ordinary in legal processes. At the least, discrimination and retaliation have been sufficiently argued to the court to allow the cases to move forward. The plaintiff has proven malice on the hospital's part in order to bring further evidence forward that the hospital was withholding (not sure if this is to be able to prove whether a defamation case can be moved forward or dismissed). Plaintiff has not proven contract expectancy or a right to be kept on for 3 years. Immunity from liability of the defendants has been denied.

 

[Claudine]

Thank you, for all your support in my case. Though I do not personally know you, I appreciate all your positive advice. At the moment my case has been dismissed but due to the overwhelming evidence I have against the program, I will be appealing this. Since I left the program, several residents have also left; however, I cannot at the moment explain to you their reasons but I suspect you all already know why. I have found that suing a program requires strong evidence and I would not be suing if that were not the case. Since several residents have emailed me for advice as they have been in similar situations, I thought to post here why I did what I did. Firstly, my program is an unopposed program, meaning we are the only residents in the hospital, there were no surgical, OB/Gyn, pediatrics, ER or IM residents, only us FPs. Thus, we would function as surgical, OB/Gyn, pediatrics, ER and IM residents and our calls demanded it, which is why duty hours were in question. Secondly, some male residents had in service scores well below mine, some residents had even failed rotations and failed step 3. My in-service scores were well above the national average, and I even had passed my step 3. Finally, I was one of only two residents ever to have won a STARS award for excellent patient care. Regardless of this, you can all guess what they tried to turn me into. Again, suing is not an easy feat but my program left me with no real choice. Since they did not accept my first year where I had passed all my rotations how could I trust them and accept the one year probation with repeating my first year? Lastly, I documented everything. Therefore, hope this answers your questions. Good luck to all of you in similar situation. God bless.
-C

 

[VirginiaRes]

I am a current resident and would just like to make a comment about this residency. I do not know much about the details of the lawsuit and do not feel it is my place to speak about that anyway as I am not involved. This is the most recent article about the summary dismall of the lawsuit:
http://www.nvdaily.com/news/2011/02/dismissal_of_womans_claim_leads_to_appeal-print.html

The only thing I do think I am qualified to talk about is the residency program. I came as a student for a rotation and loved the program, the attendings, and the clinics/hospitals. I chose this program as my top choice because of how invested the attendings are in your success and how close everyone is in the program. I would go to any attending with any problems without fear of reprisal...problem is, I have yet to have any, even minor, complaint. In addition, I have not once gone over 80 hours of work and in fact I find it annoying that they will make no exception for staying over hours for lectures you might want to attend. Only exceptions are for continuity OBs and most of the time they stay well within hours. We log our hours daily and recently my weekly hours have been around 50-60 hours per week for the last two months. We have call q9 since January of this year which is amazing. I would choose this residency again in a heartbeat and will stay in touch with many of these attendings for years to come. I hope some of you, if you are medical students will have the opportunity to enjoy this program too.

 

[Phyozo]

I am a current resident and would just like to make a comment about this residency. I do not know much about the details of the lawsuit and do not feel it is my place to speak about that anyway as I am not involved. This is the most recent article about the summary dismall of the lawsuit:
http://www.nvdaily.com/news/2011/02/dismissal_of_womans_claim_leads_to_appeal-print.html

The only thing I do think I am qualified to talk about is the residency program. I came as a student for a rotation and loved the program, the attendings, and the clinics/hospitals. I chose this program as my top choice because of how invested the attendings are in your success and how close everyone is in the program. I would go to any attending with any problems without fear of reprisal...problem is, I have yet to have any, even minor, complaint. In addition, I have not once gone over 80 hours of work and in fact I find it annoying that they will make no exception for staying over hours for lectures you might want to attend. Only exceptions are for continuity OBs and most of the time they stay well within hours. We log our hours daily and recently my weekly hours have been around 50-60 hours per week for the last two months. We have call q9 since January of this year which is amazing. I would choose this residency again in a heartbeat and will stay in touch with many of these attendings for years to come. I hope some of you, if you are medical students will have the opportunity to enjoy this program too.

While I definitely appreciate the input, as a general rule, I heavily advise other medical students to stay away from programs that have a history of terminating residents. You may have an excellent experience, and most residents do, but the potential costs far outweigh the benefits. Don't touch these programs.