List of Programs That Terminate Residents

[NotAProgDirector]

As far as the whistleblower thing, I think it depends on timing. If a resident is doing fine, then "blows the whistle" on something, and then all of a sudden is getting fired, that seems like something that needs protection. On the other hand, a resident who is not doing fine and headed towards being fired who then "blows the whistle" on something, that's more complicated. Depending on how it's worded, whistleblower protections could be used as a shield by truly incompetent interns. This unfortunately happens frequently -- when an intern/resident is in the process of being terminated, they all of a sudden start blaming the system -- saying that their duty hours were too long, or that they were discriminated against, etc. It's hard sometimes to tell who is telling the "truth" -- my experience is that often the resident fully believes that they are not at fault, that everyone else is having the same problems, that they are getting better, and that there is nothing wrong with them.

Now, I do totally agree with you that the current system is ripe for abuse. There is nothing to stop a PD from doing exactly the above -- either blowing things out of proportion, or frankly making things up about a resident. And, as pointed out, it can be difficult for a resident who is terminated from one program to find a spot in another -- not surprising, since it's hard to prove that any prior problems have been "fixed" or that they never existed in the first place. And, when a resident does not work out for a program, it's usually a huge problem, creating schedule chaos, etc.

At present, I do agree that the system does not have enough safeguards for residents. Unfortunately, I don't see any easy way to fix it.

Already it's mandated by the ACGME that there be an evaluation committee. So, rather than just the PD's say-so, a whole committee is supposed to review resident performance. This is no real protection, since some "malignant" PD's will simply rule by fiat, and the committee will simply rubber stamp anything they want. Plus, the committee can be easily swayed by selective evidence.

We could require that the PD submit a final evaluation letter to the ACGME. The resident should be able to see this letter, and perhaps they could submit a rebuttle -- or have faculty at the program do so. This could be private, so that the PD wouldn't know who had written what. When applying for a new position, the resident would refer PD's to the ACGME for the letters. However, I find it hard to believe that a PD wouldn't contact the prior PD even after reading the letter, and there is no way to control what is said in that conversation. Still, this is relatively easy and inexpensive, and wouldn't be hard to implement. It might make the system somewhat better.

A really crazy idea is to require that the resident reliquish their training funds. So, if I terminate a PGY-1, I can only get the funds for a new PGY-2 if I have the "release" from that PGY-1. This would give residents a huge lever to use with PD's. Still, I don't see this working on many levels. First, it's never going to happen politically. Second, I could see residents basically demanding an "OK" letter, even if their performance was not OK. Last, once I had the release, I'd be free to say anything I wanted about the resident (and if I was blackmailed into writing a better letter than I wanted, you can be certain that I wouldn't have good things to say).

Perhaps the best solution is a different idea. There is going to be no way to fairly assess a resident who is terminated if they contest the process. It will always turn into a he said ./ she said sort of situation, and determining the truth will be impossible. So, perhaps, forget about that. Instead, what a terminated resident needs is another chance, but programs are usually unwilling to take a resident like that in, since they are unwilling to make a long term commitment. However, it is not infrequent that my program has a hole in it's schedule -- maybe a resident takes a maternity leave, or someone transfers to another field, etc. PD's might be willing to take a resident on a temporary basis -- you'd work for 3-4 months, with no promise of further training. But, it would give you a chance at a new program, perhaps a new field, and generate a new PD letter. I could imagine ACGME keeping a database of people looking for spots. Theoretically this could include people who had no residency training (i.e. who couldn't match) but wanted some experience, but I would imagine that most PD's would prefer someone with some experience already.

Still, I'm not sure that even this would work. If I had a hole in my schedule, would I find a way to fill it using my own resources, or hire someone who might be yet a new problem to deal with? I guess it would depend upon their story, and how much of a risk I thought it was.

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[NotAProgDirector]

Thinking about this problem more, something occured to me:

Why do we need to care about program directors or their residencies at all?

And the answer to that is simple: The American Board of Medical Specialties. http://www.abms.org/ They are private. They are unelected. They answer to nobody. And they set the rules that govern everything else behind our GME system.

We all know this, and yet we never discuss it.

They require years of underpaid service in APPROVED programs only in order to be BC/BE in a given field. It's not like law or business where you "specialize" in a field simply by putting hours in at a private firm -- or on your own. You must "match" into a business entity which, as we all know, will pay you less than minimum wage for long hours of work while dangling the one carrot of "Board Eligibilty" in front of you, while you must try to ignore the Sword of Damocles that might drop down at any time should you fall out of personal favor with the one person anoited with the title of Program Director.

Because of this system, intentionally set up by the American Board of Specialty as well as their clients at the ACGME, we are at the mercy of a singular Program Director for our 3-5 years of residency, a person who can end our careers with a snap of his fingers with zero repercussions to himself

A lawyer does not have to put in 3 years in a Family Law residency to become a divorce lawyer, during which time his career can be ended (or saved, in the case of incompetency, which is a far worse crime) at any time on the sole whim of his Program Director. A businesswoman does not have to put in 4 years in a Stock Exchange residency to become a stock broker. A CPA does not have to put in 5 years in a Corporate Accounting residency to become a corporate accountant. All of these examples are insane on their face.

The root of the problem is the ABMS. We should not blame the ACGME -- as we all know, they are a toothless client organization. If we could sit for written and oral board exams without having to jump through insane hoops set by this private, unelected, non-government agency first, the problem would remedy itself. People could choose to work in private practice to avoid malignant PDs, which would rob the same malignant PDs of their power overnight. And medicine would be brought back in line with every other educated profession such as law and engineering.

Why can't this be done?

(edit: the one saving grace for many people is that our nation's laws have not caught up to the ABMS's vision of medical education. States still do not require ABMS board certification in one of their 24 specialties to become licensed. This is a relic of the past, pre-1970s, when most docs did not even go through more than 1 year of residency, but it allows a way for docs to still put food on their table despite their PD's wishes.)

I am going to disagree with your thoughts here. There is no question that anyone who graduates from medical school needs more training prior to actually practicing -- so the thought that people could just go out on their own is crazy. And, we've lived in a world where there were no residencies -- people simply apprenticed to someone, or set up shop on their own. That system was open to abuse too, and the majority of people got bad training.

Taking the ABIM (or insert any other ABXX here) is NOT a measure of competence. I am certain that I could read/study about how to fly a plane, and then take a test and pass it. That does not make me competent to fly a plane. There is a ton of practical knowledge that you need to learn that does not lend itself to testing well -- hence a residency and evaluations from your supervisors.

So, I agree that the system needs some fixing. But getting rid of the system is not the solution IMHO.

 

[ForbiddenComma]

I see your point, and there does need to be a system of graduate medical education of some sort, no doubt... but if there is to be some scale of competency above and beyond the board exams, that scale needs to be something other than "the whims of one person holding a specific title." I saw a number of incompetent residents waved-through at my program simply because they were in the PD Dr. Lazerson's, favor, and he reached out to the attendings to smooth things over. And since "board-eligible" is almost as good as "board-certified," especially for the first few years post-residency, this has scary implications for the patients.

I am not sure what the perfect solution is, but the current system, where PDs are given near-godlike powers by the ABMS, has to surely be among the worst of the possible options.

 

[peerie]

I think that Forbidden has some good points and I am glad to see his/her honesty. Thank you also aProg for your honest comments, your honesty goes a long way when discussing something as frightening and serious as this topic.


I also was forced to resign from a program that turns out to have a history of forced resignations. I didn't know that of course when I started, but it quickly became obvious. Community attendings laughed about how they had forced the PD to fire certain residents, and how proud they were that they had made that happen (the attending). I was shocked but kept my head down. Eventually, it was my turn. Faculty were decent enough but weak, the community docs ruled.


Three other residents left after I did. For me, I was told I had excellent knowledge ('a very fine intelligence'), was fast and very liked by staff and patients and most residents. I was told in the end however: "we just don't like your personality."


Does it make sense? is it right? it seems a very sad waste of an excellent education I suppose, but in the end maybe I am the lucky one. Medicine is a very troubled place, and from my own experiences as well as those of many, many others I can say that maybe we are better off out of such an environment. We enter medicine with such ideals and goals, but the gritty truth is harder to take. I don't regret going to medical school, I enjoyed my first two years of classes and the pre-med work alot.

Life in the end has a way of putting us where we are meant to be, and so there it is. Just my thoughts -

 

[MD forever]

I hope you have completed at least one year ACGME under your belt, Get step three USMLE off your check list and apply for license in state that you like and meet their requirements. Move on with your career. Wish you the best

 

[residentdoctor]

I am going to disagree with your thoughts here. There is no question that anyone who graduates from medical school needs more training prior to actually practicing -- so the thought that people could just go out on their own is crazy. And, we've lived in a world where there were no residencies -- people simply apprenticed to someone, or set up shop on their own. That system was open to abuse too, and the majority of people got bad training.

Taking the ABIM (or insert any other ABXX here) is NOT a measure of competence. I am certain that I could read/study about how to fly a plane, and then take a test and pass it. That does not make me competent to fly a plane. There is a ton of practical knowledge that you need to learn that does not lend itself to testing well -- hence a residency and evaluations from your supervisors.

So, I agree that the system needs some fixing. But getting rid of the system is not the solution IMHO.

That is right -- the system needs some fixing. Residents need to be trained in order to practice. Even practicing physicians need to refresh/update medical knowledge and to improve their clinic skill via meeting and learning from co-workers through the whole career.
A resident needs to be evaluated from the supervisors, but in the meantime, a resident needs to be trained by the supervisors too-- the supervisors act like both boss and instructor. Lots of the time, the supervisor ( including some PD and attendings) is a power trick but not a good and not kind or not a dedicated mentor, it is very easy for a supervisor to target a " trouble resident" and give him/her a hard time during the job in the excuse of professionism eventually toward " fired and terminated" phase.

 

[zihuatanejo]

As far as the whistleblower thing, I think it depends on timing. If a resident is doing fine, then "blows the whistle" on something, and then all of a sudden is getting fired, that seems like something that needs protection. On the other hand, a resident who is not doing fine and headed towards being fired who then "blows the whistle" on something, that's more complicated. Depending on how it's worded, whistleblower protections could be used as a shield by truly incompetent interns. This unfortunately happens frequently -- when an intern/resident is in the process of being terminated, they all of a sudden start blaming the system -- saying that their duty hours were too long, or that they were discriminated against, etc. It's hard sometimes to tell who is telling the "truth" -- my experience is that often the resident fully believes that they are not at fault, that everyone else is having the same problems, that they are getting better, and that there is nothing wrong with them.

Now, I do totally agree with you that the current system is ripe for abuse. There is nothing to stop a PD from doing exactly the above -- either blowing things out of proportion, or frankly making things up about a resident. And, as pointed out, it can be difficult for a resident who is terminated from one program to find a spot in another -- not surprising, since it's hard to prove that any prior problems have been "fixed" or that they never existed in the first place. And, when a resident does not work out for a program, it's usually a huge problem, creating schedule chaos, etc.

At present, I do agree that the system does not have enough safeguards for residents. Unfortunately, I don't see any easy way to fix it.

Already it's mandated by the ACGME that there be an evaluation committee. So, rather than just the PD's say-so, a whole committee is supposed to review resident performance. This is no real protection, since some "malignant" PD's will simply rule by fiat, and the committee will simply rubber stamp anything they want. Plus, the committee can be easily swayed by selective evidence.

We could require that the PD submit a final evaluation letter to the ACGME. The resident should be able to see this letter, and perhaps they could submit a rebuttle -- or have faculty at the program do so. This could be private, so that the PD wouldn't know who had written what. When applying for a new position, the resident would refer PD's to the ACGME for the letters. However, I find it hard to believe that a PD wouldn't contact the prior PD even after reading the letter, and there is no way to control what is said in that conversation. Still, this is relatively easy and inexpensive, and wouldn't be hard to implement. It might make the system somewhat better.

A really crazy idea is to require that the resident reliquish their training funds. So, if I terminate a PGY-1, I can only get the funds for a new PGY-2 if I have the "release" from that PGY-1. This would give residents a huge lever to use with PD's. Still, I don't see this working on many levels. First, it's never going to happen politically. Second, I could see residents basically demanding an "OK" letter, even if their performance was not OK. Last, once I had the release, I'd be free to say anything I wanted about the resident (and if I was blackmailed into writing a better letter than I wanted, you can be certain that I wouldn't have good things to say).

Perhaps the best solution is a different idea. There is going to be no way to fairly assess a resident who is terminated if they contest the process. It will always turn into a he said ./ she said sort of situation, and determining the truth will be impossible. So, perhaps, forget about that. Instead, what a terminated resident needs is another chance, but programs are usually unwilling to take a resident like that in, since they are unwilling to make a long term commitment. However, it is not infrequent that my program has a hole in it's schedule -- maybe a resident takes a maternity leave, or someone transfers to another field, etc. PD's might be willing to take a resident on a temporary basis -- you'd work for 3-4 months, with no promise of further training. But, it would give you a chance at a new program, perhaps a new field, and generate a new PD letter. I could imagine ACGME keeping a database of people looking for spots. Theoretically this could include people who had no residency training (i.e. who couldn't match) but wanted some experience, but I would imagine that most PD's would prefer someone with some experience already.

Still, I'm not sure that even this would work. If I had a hole in my schedule, would I find a way to fill it using my own resources, or hire someone who might be yet a new problem to deal with? I guess it would depend upon their story, and how much of a risk I thought it was.

With all due respect, your reform proposals don't amount to a hill of beans and are just tinkering around the edges. What we need is far more radical reform. However, radical doesn't mean complicated. Radical reform can be simple in many ways but would not be easy to implement given how traditional medical culture is and how resistant it is to change. What we need is a system in which one person (i.e. program director) does not have unfettered power to destroy nascent medical careers and abuse and intimidate residents. Moreover, program directors need to be held accountable for any abuses of power that they engage in. Perhaps, an independent and neutral review panel could be establised to review and make final decisions regarding resident terminations. Such a body would have both faculty and resident members on it, and could be establised through funding from GME programs and residents. That body would also run completely anonymous surveys of residents and conduct unannounced site visits of residency programs. Based on the results of those surveys and site visits, this body would have the authority to terminate incompetent and abusive residency program directors. In addition to this, having a national resident union with clout (and representation on the aforementioned review panel) would also help.

 

[IlDestriero]

More some PD and some programs won't allow other individual attending whom the terminated resident worked with and did do a decent job to write any letter to say nice things about the terminated resident or even a few objective things regarding his/her performance.

This is ridiculous. The program director holds no power over me or any other faculty. I could write a LOR for anyone I wished. They wouldn't even know, and if they found out, who cares? If some attending physician is telling you that they "are not allowed" to write you a letter, it's because they don't have the courage to tell you that they choose not to write you one or they feel they are unable to give you a positive recommendation.

 

[ForbiddenComma]

This is ridiculous. The program director holds no power over me or any other faculty. I could write a LOR for anyone I wished. They wouldn't even know, and if they found out, who cares? If some attending physician is telling you that they "are not allowed" to write you a letter, it's because they don't have the courage to tell you that they choose not to write you one or they feel they are unable to give you a positive recommendation.

I admire your courage, but many others do not exactly share your spine.

Some of it is understandable. At many programs, including my former one, attendings who draw a paycheck directly from the school (in lieu of, or in addition to, compensation from the doc group/hospital) will have the PD as their supervisor. Other times, attendings who are not directly on the school's payroll simply don't want to stick their neck out for anyone who is out of favor because they know they are going to be around the PD and his program for years to come, as opposed to some random resident with no power or influence. And some may indeed be insulated from the politics, as you imply you are... but almost by definition, those attendings will have little contact with the residents and thus won't make for the best LORs.

My PD did everything in his power to try and end my career, and his power among the physician community in that town cannot be overstated. He was not successful, fortunately, and some attendings wrote me impartial letters for which I remain grateful. But other residents are not so fortunate, and find their dreams and careers smashed to pieces over the whims of some petty tyrant with an artifically-inflated title.

 

[peerie]

When I asked attendings who had given me excellent evals to write me a letter I was told by one that he did not dare to jeopardize his career by helping me. Another initially was shocked when I told him I had left, he said to come and talk with him and he would do whatever he could to support me. When I went to see him a week later, he refused to acknowledge me and kept me waiting in the waiting room for almost three hours. Finally, I just left.

And one very decent community doc initially wrote me a very supportive letter for the scramble and was very good to me. She also was very devastated about my being forced to resign. She said: "you were an intern, you were there to learn." When I went through the match again she would not even talk to me, and her assistant told me she 'would help me if she could.'

In the end, these are very sad people who have to behave like that. How does this serve anyone? I believe there is a greater presence in charge and that there is also a sense of 'karma.' What we do comes back on us, and I wouldn't want to walk in their shoes. I am sorry that medicine is like this. I didn't expect it would be and so I guess I wasn't fully prepared. I have learned alot from these experiences, as you do with any significant life changes and feel I am a better person for what I have learned.

 

[ForbiddenComma]

In the end, these are very sad people who have to behave like that. How does this serve anyone? I believe there is a greater presence in charge and that there is also a sense of 'karma.' What we do comes back on us, and I wouldn't want to walk in their shoes. I am sorry that medicine is like this. I didn't expect it would be and so I guess I wasn't fully prepared. I have learned alot from these experiences, as you do with any significant life changes and feel I am a better person for what I have learned.

It is indeed frustrating. Sometimes, it is better to not have an LOR to begin with from some people though.

Here is a sad little story. During my ordeal, I asked for and received a glowing LOR from the asst. program director, one Dr. Larsen, who had acted like my friend and mentor. This was one heck of a letter that even the Surgeon General would have been proud to receive. And, she was the asst. PD. Obviously, I was going to feature this letter in my apps.

Not long after, I received word from the PD that she had gone along with the PD in all his malignant actions to try and get me fired, and had voted with him each time to terminate me. (it was the chair who saved me each time -- not all people are bastards.) Anyway, when I asked her about, she did not deny it and simply told me never to contact her again! Obviously, had the PD not tipped his hand, I would have listed her as a reference and she would have savaged me on the phone to anyone who called, which was no doubt the idea all along. That is how some people behave.

People do ask how anyone, let alone medical professionals, act in such petty, duplicitous or malignant ways that would be too shocking for an episode of Real Housewives. To that, I have no answer other than: getting an MD does not make someone less cunning, backstabbing or just plain nuts. All it does is give them cover.

 

[residentdoctor]

When I asked attendings who had given me excellent evals to write me a letter I was told by one that he did not dare to jeopardize his career by helping me. Another initially was shocked when I told him I had left, he said to come and talk with him and he would do whatever he could to support me. When I went to see him a week later, he refused to acknowledge me and kept me waiting in the waiting room for almost three hours. Finally, I just left.

And one very decent community doc initially wrote me a very supportive letter for the scramble and was very good to me. She also was very devastated about my being forced to resign. She said: "you were an intern, you were there to learn." When I went through the match again she would not even talk to me, and her assistant told me she 'would help me if she could.'

In the end, these are very sad people who have to behave like that. How does this serve anyone? I believe there is a greater presence in charge and that there is also a sense of 'karma.' What we do comes back on us, and I wouldn't want to walk in their shoes. I am sorry that medicine is like this. I didn't expect it would be and so I guess I wasn't fully prepared. I have learned alot from these experiences, as you do with any significant life changes and feel I am a better person for what I have learned.

well, that is what exactly happening to the terminated residents mostly of the time. Other attendings ( including other specialities ) expressed their empathy, writing LOR for the terminated resident will jeopadize their career and also making the PD and program looking bad. It is very unfortunately happening in the medical resident training-- everyone outside the medical field will think physician should be one of the kindest person in the world-- helping others. When someone gets fired from his/her job, he/she still can get reference from his/her co-workers other than his/her boss. But not for the terminated residents-- they are the ones supposed to be trained and getting professional improved. They are not the ones who commit to crimes/neglect/incidents to patient. They are the trainee who could not answer the medical questions in a second. When PD and his/her fellow attendings over use his/her power, the action becoming a blockage. It is very sad the see a mentor to do that-- not being an advocator or inspired instructor instead of becoming a judge from a court to sentence a resident.

 

[wooster201106]

...Taking the ABIM (or insert any other ABXX here) is NOT a measure of competence. I am certain that I could read/study about how to fly a plane, and then take a test and pass it. That does not make me competent to fly a plane. There is a ton of practical knowledge that you need to learn that does not lend itself to testing well -- hence a residency and evaluations from your supervisors.

So, I agree that the system needs some fixing. But getting rid of the system is not the solution IMHO.

The ABIM (and many others) would probably disagree with you. The certification exam is meant to measure medical knowledge, which is at least one facet of the competence required to practice medicine; for a mainly non-procedural specialty like general internal medicine one could argue it is the major one. I'm sure there are those who could study for and pass the certification exam without a single day of residency training, and, of course, there are many who fail despite successfully completing residency.

Notwithstanding those who fail due to myriad extenuating circumstances, I'm not sure which worries me more; the one who passed the exam with only the practical and medical knowledge obtained from successful completion of medical school and independent study, or the one who, despite years of residency training and didactics, is unable to pass the exam. There are no examples of the former, but plenty of the latter. I'm not aware of any available evidence to suggest that one is more competent to practice than the other. The obvious assumption would be that the one with residency training would be more competent, but again, where is the evidence? Anecdotal doesn't count. Certainly, this would only apply to specialties that don't require technical/procedural proficiency which can really only be acquired through training and experience.

In my admittedly short medical career thus far, I've already been witness to residents with deficiencies obvious to anyone in proximity who've been allowed to graduate and proceed to fellowship. Not surprisingly, they also failed their certification exam. Conversely, I've also been surprised by those who seemed very competent clinically but failed the exam.

"Certification by the American Board of Internal Medicine (ABIM)...has meant that internists have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care."

By including "attitudes" in their statement, they're essentially stating that not only is certification a "measure" of clinical competence, but also of one of the behavioral components of another "competence" which is typically only evaluated through observation in residency or other practical setting, that of "professionalism".

 

[wooster201106]

...Moreover, program directors need to be held accountable for any abuses of power that they engage in. Perhaps, an independent and neutral review panel could be establised to review and make final decisions regarding resident terminations. Such a body would have both faculty and resident members on it, and could be establised through funding from GME programs and residents...

This is a pipe dream. Any independent panel would require both political support and funding, both of which are nonexistent. We seem to be heading towards greater austerity in graduate medical education, and creating another layer of bureaucracy and the funding it entails is just not realistic. More importantly, the political or popular support for such a venture does not exist on either side. Unfortunately, I don't believe the kind of reform of which you speak will ever happen. It would most certainly not be top-down but would most likely only happen through a grassroots-type movement. Considering the vast power differential between programs and their trainees and how easily they can be intimidated, combined with the fact that cases discussed in threads such as these still represent only a very small percentage of the total number of trainees currently in GME programs, I don't see that happening.

That body would also run completely anonymous surveys of residents and conduct unannounced site visits of residency programs. Based on the results of those surveys and site visits, this body would have the authority to terminate incompetent and abusive residency program directors.

Another pipe dream. I think we all know by now that these kinds of surveys are not anonymous.

 

[zihuatanejo]

I don't have any illusions that any change on the scale that I proposed will ever come to fruition for the reasons that you have discussed. What I am doing is merely engaging in an academic exercise on how to best protect residents from being unjustly terminated and blacklisted by malignant residency program directors. You seem to have done a good job of arguing that my ideas are not feasible and I don't necessarily disagree with the gist of your analysis, but you haven't presented any alternative ideas of your own that you think are more likely to be implemented. Perhaps you don't think the system needs to be reformed for the sake of "the very small percentage" of residents who get victimized. I guess that I am not surprised by that attitude because premedical and medical training does tend to reward cut-throat and selfish behavior where narrow self-interest trumps everything else.

I disagree with your description of anonymous surveys as not being anonymous. Even the ACGME surveys are anonymous. The problem is that residents are afraid that the program might retaliate against them if they give negative ratings on the survey. Programs might try to guess which residents might have given them negative ratings. A disgruntled resident or one who complains alot would be a natural suspect and would face retaliation. The problem there is not so much that the surveys are not anonymous but that programs are free to retaliate and intimidate residents without facing any consequences or accountability for engaging in such behavior. In the scheme that I outlined (granted it is likely never going to be implemented without the type of revolutionary change that you described) the programs would face severe consequences if they retaliate against, discriminate againist, mistreat, harrass, intimidate, or otherwise target individual residents for any reasons that are not performance related, and the organization conducting the surveys would have the authority to terminate program directors once a certain threshold of resident concerns or complaints is reached. The ACGME currently has no such authority and is essentially a worthless and toothless organization when it comes to protecting individual residents who are targeted by programs.

 

[ForbiddenComma]

Any reform would never come from our current alphabet soup of organizations such as the ACGME, ABMS, etc. It would have to come from the federal government.

You know... that institution that funds 90%+ of all residency slots through Medicare.

People need to work to raise awareness of the problem of malignant GME programs to their congresspeople and their senators. This isn't just about random people having their careers ended for no good reason. The real problem is the impact on future patients where incompetent doctors are made board-eligible as long as the malignant PD waves them through, which is the flipside of malignancy that nobody likes to talk about.

 

[member0007]

I think that Medicare and the US government needs to take greater responsibility for the funds that is disbursed to posh instituitions to educate a physician in training. I would rather that there was some way to make sure that healthcare was more equitable and not a business to make money. Most civilized countries have a socialized health care system, AND the medical school education is paid by the government. HMM... my friends have been bringing up this particular model for an healthcare system for eons. I mean what's the point of paying thousands of dollars for a medical education that is essentially loaned by the government and only to have to pay back the goverment. In the meantime, during residency, the government is shelling out approximately 2 to 4 times what you paid for medical school to hospitals as part of the GME funding plan to a particular hospital for your time. This ensures that you then pay back the government over the years, let's say 30 or so, at an interest, allowing the government to collect on it's investment that it made on your education. This is essentially the system that we have right now. Therefore, I have finally come to see their point of view, which is have the education be funded. Apply for residency like it's any other job, not some match making algorithm.

 

[IlDestriero]

Any reform would never come from our current alphabet soup of organizations such as the ACGME, ABMS, etc. It would have to come from the federal government.

You know... that institution that funds 90%+ of all residency slots through Medicare.

People need to work to raise awareness of the problem of malignant GME programs to their congresspeople and their senators. This isn't just about random people having their careers ended for no good reason. The real problem is the impact on future patients where incompetent doctors are made board-eligible as long as the malignant PD waves them through, which is the flipside of malignancy that nobody likes to talk about.

I don't think program directors and the other faculty are passing incompetent residents. Sorry. If we had a truly incompetent fellow, they wouldn't graduate. The end. There's no reason to compromise the reputation of the program to give a certificate to some random resident with a nice smile and a pleasant demeanor. You may think they are incompetent, but that doesn't mean that they are.

 

[ForbiddenComma]

I don't think program directors and the other faculty are passing incompetent residents. Sorry. If we had a truly incompetent fellow, they wouldn't graduate. The end. There's no reason to compromise the reputation of the program to give a certificate to some random resident with a nice smile and a pleasant demeanor. You may think they are incompetent, but that doesn't mean that they are.

That's nice.

Can you say the same thing about every single other residency and fellowship across the country?

 

[IlDestriero]

That's nice.

Can you say the same thing about every single other residency and fellowship across the country?

Sure. There's no reason to pass an incompetent resident, and there is no reason for the other faculty to allow it to happen. If I'm on the faculty and some truely incompetent resident gets passed along, he's a danger to MY patients, MY reputation, and MY career. Got to go Bro, and quick. I'm not going to let some random resident or fellow jeopardize my livelihood, my future, my family just because they're nice, or charming, or whatever. Think about that for a minute. Why would the faculty sit idly by and allow that to happen?
You seem to think that the PD has some position of power over the other faculty, they don't. They manage the residents or fellows and do some work. I do my own job and handle my own administrative responsibilities. My boss is the Chair, his boss is the hospital CEO. The Dean fits in there as well, sort of, as they have to sign off on my promotion and reappointments at the medical school. The PD doesn't fit in to my chain of command anywhere. He/She's in no position to coerce me to do anything.
The one resident that got thrown out of my program while I was there was a bright and personable physician, they just didn't have the proper personality to be able to handle the stress of anesthesia as a career. The PD and the resident both eventually agreed on that. They went on to PM&R. A perfect fit. With the full support of the PD and the other faculty. Including the faculty that stood up at the resident review meeting and railed against him.

 

[ForbiddenComma]

Sure. There's no reason to pass an incompetent resident, and there is no reason for the other faculty to allow it to happen.

See, you are once again assuming that all program directors across the entire country always act logically, and that is the fallacy of your argument.

Yes, it makes no logical sense to cover for incompetent residents. Yes, it makes no logical sense to fire competent residents just for kicks. But so what? Do you really think that doctors, or program directors, are somehow immune to the office politics, petty jealousies and plain old malignancy that infects every other human operation on earth?

You said that you got only 1 resident thrown out, and you also made sure they had a good landing in a different field. What you are describing is a non-malignant program. That is how it should be. And yet, I assure you, not all programs are like this. Some PDs just like to play favorites, and they are granted the power of life-and-death over their residents by weak, spineless deans or hospitals (like at my old program) that never review their actions. The dean of GME at my old place told me to my face that 1) my program is malignant and 2) she "didn't know" what to do about it. It was a true profile in courage.

What check do you think exists over the PD in this malignant situation? The ACGME? Surely you are not that naive!

Again, horrible programs happen. Same as any other profession. That's life; that is not what's at issue. The problem is the outsized influence these horrible program directors have over their former charges for the rest of their lives. Since only one person is the only real reference that matters for future GME programs as well as all 50 state medical licensing boards, the PD has the power to grant BE status to even the worst resident, or to terminate even the best resident. There is no check to their power.

I am glad that your program chooses not to be malignant, but consider: if you guys DID choose to be malignant, what check would their be on you?

 

[peerie]

Maybe if more people do discuss this topic rationally and with honesty, we can make some important changes for those trainees who follow.

 

[IlDestriero]

There is no fallacy in my argument, being malignant and abusing residents and playing favorites and office politics is completely different from your other assertion, the one that I commented on btw. That is your assertion that incompetent residents are passed on and certified board eligible. I find that assertion extraordinarily unlikely. One can be weak, abrasive, introverted, arrogant, whatever negative adjective you want, but not incompetent. If you're really incompetent, your charm can only cover your stupidity and/or poor judgment for so long. The PD can try to remediate you, mentor you, etc. but if you're truly incompetent, you're not going to graduate. We've had underperforming, weak fellows but they were not incompetent or unsafe, just not future superstars, and certainly not faculty material. If they were, they'd be history.
PS I didn't get anyone thrown out, but I was just elected chief, and I had to deal with the scheduling nightmare that remained after their departure.

See, you are once again assuming that all program directors across the entire country always act logically, and that is the fallacy of your argument.

Yes, it makes no logical sense to cover for incompetent residents. Yes, it makes no logical sense to fire competent residents just for kicks. But so what? Do you really think that doctors, or program directors, are somehow immune to the office politics, petty jealousies and plain old malignancy that infects every other human operation on earth? You said that you got only 1 resident thrown out, and you also made sure they had a good landing in a different field. What you are describing is a non-malignant program. That is how it should be. And yet, I assure you, not all programs are like this. Some PDs just like to play favorites, and they are granted the power of life-and-death over their residents by weak, spineless deans or hospitals (like at my old program) that never review their actions. The dean of GME at my old place told me to my face that 1) my program is malignant and 2) she "didn't know" what to do about it. It was a true profile in courage.

What check do you think exists over the PD in this malignant situation? The ACGME? Surely you are not that naive!

Again, horrible programs happen. Same as any other profession. That's life; that is not what's at issue. The problem is the outsized influence these horrible program directors have over their former charges for the rest of their lives. Since only one person is the only real reference that matters for future GME programs as well as all 50 state medical licensing boards, the PD has the power to grant BE status to even the worst resident, or to terminate even the best resident. There is no check to their power.

I am glad that your program chooses not to be malignant, but consider: if you guys DID choose to be malignant, what check would their be on you?

 

[ForbiddenComma]

There is no fallacy in my argument, being malignant and abusing residents and playing favorites and office politics is completely different from your other assertion, the one that I commented on btw. That is your assertion that incompetent residents are passed on and certified board eligible. I find that assertion extraordinarily unlikely.

Well, how many quacks are you familiar with in your community? Which are the doctors whose names you dread seeing on any medical record? Whose mistakes are you all having to clean up after constantly? How about doctors in your ER who have become notorious? If you are like most areas, I am guessing this is a non-zero number.

That means some program somewhere passed these quacks and allowed them to become board eligible.

Again, your program sounds great. I am glad you all don't pass quacks because they are liked or fire good residents because they are disliked by your PD. Please do not think I am trying to generalize to all programs in this country. But, sadly, there are quite a few malignant program directors that either pass bad residents, fire good residents, or both, because they know they have all the power in the world. And there is virtually no check or quality-control mechanism in place to bring these malignant PDs in line. *That* is the problem that needs to be addressed at the federal level.

 

[member0007]

honestly, a lot of the incompetency issues are very subjective. in fact, there are a lot of doctors out there who don't even have certifications etc but work towards it over a time period. there are some that can't make the cut even if they are certified because they can take a test and pass but not be able to practice competently. however, for a residency program to outright label an individual as being an incompetent doctor after years of service is a major warning sign of a malignant program. also, take a look at the person who is labeling you incompetent, how competent are they?

imho and after what i have been thru, it's better for a resident to leave a hospital where they feel that they don't belong at. residency is a longitudinal and challenging aspect of medical education that takes anywhere from 3-7 or even more years sometimes with added fellowships to complete. if you are a physician who is not being appropriately supported or there is that overwhelming evidence that punitive actions are taken against you, it might be better for your well-being to resign, instead of feeling harassed and threatened or intimidated on a periodic basis and uncertain of what is expected of you to meet their requirements etc etc etc.

 

[residentdoctor]

honestly, a lot of the incompetency issues are very subjective. in fact, there are a lot of doctors out there who don't even have certifications etc but work towards it over a time period. there are some that can't make the cut even if they are certified because they can take a test and pass but not be able to practice competently. however, for a residency program to outright label an individual as being an incompetent doctor after years of service is a major warning sign of a malignant program. also, take a look at the person who is labeling you incompetent, how competent are they?

imho and after what i have been thru, it's better for a resident to leave a hospital where they feel that they don't belong at. residency is a longitudinal and challenging aspect of medical education that takes anywhere from 3-7 or even more years sometimes with added fellowships to complete. if you are a physician who is not being appropriately supported or there is that overwhelming evidence that punitive actions are taken against you, it might be better for your well-being to resign, instead of feeling harassed and threatened or intimidated on a periodic basis and uncertain of what is expected of you to meet their requirements etc etc etc.

That is true that not just residency is a longitudinal aspect of medical education, even practicing physician who must keeps CME for the life time. And residents are the lowest starter of medical practicing career. As the starter, already labelled as incompetent by PD to be terminated in a few months of residency training or almost the end of residency training. PD and some attendings can be fired from their hospital, but they can still get a job to practice in stead of being an instructor. But for terminated residents ( especially IMGs)-- they are the ones who will be struggling even find a job later on, maybe have to give up all these years medical educations to work in other field or go to school again for other field. That is why if any physician who chooses to be a resident mentor ( PD or other resident attending), should have basic ethic standard as a teacher/instructor, just like being health provider-- can not abandon a patient without offering clear explanation or plan.

 

[wooster201106]

....Perhaps you don't think the system needs to be reformed for the sake of "the very small percentage" of residents who get victimized. I guess that I am not surprised by that attitude because premedical and medical training does tend to reward cut-throat and selfish behavior where narrow self-interest trumps everything else.

That's not what I said nor could it have reasonably been inferred from my post. As someone with direct experience in the petty politics of medicine, you are preaching to the choir. I said that it would be difficult to gather support for such an undertaking given the meek nature, in general, of residents and their understandably low thresholds for acquiescence when challenged by those who have the capacity to derail their career. Fear is quite the powerful motivator and ensures that residents remain servile. So powerful, in fact, that even if a program does not have a "malignant" atmosphere, a wise resident, realizing they are easily replaceable, still wouldn't rock the boat. Couple this with the fact that this affects a small minority of trainees and you have your work cut out for you. None of this, of course, makes an unjustifiable termination less of a travesty, but the only ones who truly seem passionate about reform are those with personal experience in dealing with this issue.

You seem to have done a good job of arguing that my ideas are not feasible and I don't necessarily disagree with the gist of your analysis, but you haven't presented any alternative ideas of your own that you think are more likely to be implemented.

I may not have in that post, but had you searched prior posts you would've seen that I have offered some suggestions. I do not like "engaging in academic exercises" just for the sake of discussion nor do I care for the pontification that goes with it. I'm interested in real reform leading to something tangible which would ensure there are standards put in place and that all trainees, regardless of where they train, are treated fairly and evenly.

Currently, the ACGME only mandates that GME programs provide "due process" for trainees regarding resident evaluation and promotion. However, if you were to examine resident policies among different GME programs, as I did when I applied for the Match, you would find that how "due process" is defined can vary widely from one program to the next. Sometimes the disparities are enormous. For instance, one program I interviewed at required that an "advocate" be assigned to any resident facing remediation, termination, or non-renewal, who could serve as both a mentor and representative throughout the process. Most programs, though, lacked this as a safeguard.

Other programs stipulated certain protocols or criteria which had to be followed or met before a trainee could be terminated or their contract non-renewed, essentially limiting the program director's discretion. This of course was barring anything egregious or actions jeopardizing patient safety. For example, if some deficiency was noted, that resident would be counseled informally, or if remediated, expectations and timelines for progress would be strictly stipulated. Failing that, the process would move forward with formal probation and, if satisfactory progress had not been made, finally termination but the process was required to proceed in stepwise fashion. If terminated or placed on probation, the trainee would be entitled to an appeal at that point, but was also allowed to plead their case before the residency competency committee made any decision regarding termination. On the other hand, there were programs where the PD was provided wide discretion and none of the aforementioned safeguards were present. One program even strictly forbade residents from having counsel present during any disciplinary proceedings.

In order for any proposed reform to have a realistic chance of being implemented, it would need to enjoy both wide support and fit within the current framework established by both programs and the ACGME which means not counting on being provided additional funds or personnel. My first suggestion would be to address the wide disparities between GME programs in resident "due process" by having the ACGME establish standards or protocols to ensure that all residents are treated fairly and evenly in any disciplinary matter regardless of their institution rather than just mandating that "due process" be provided but failing to define it. This leaves open the potential for abuse. At most, I imagine this would require a panel or committee be convened to survey the issue, propose changes, and elicit feedback/opinions. I assume the cost here would be nominal.

Another suggestion would have the ACGME require programs be meticulous in their documentation and report to the ACGME all decisions regarding resident disciplinary matters. This may already be the case. In fact, I believe in such cases, the program retains everything in the resident's file in the event a lawsuit is later filed, and in contrast to only a summary evaluation that would be found in the file of a resident who completes the program. Along with resident completion rates, this information should be made public and should include detailed info, over a specified time period, regarding the number of residents terminated, non-renewed, etc. There is absolutely no reason for keeping this information private except to aid the program. If this information is required to be reported by programs to the ACGME, then its omission would serve as an obvious example of the ACGME's bias towards programs. If the ACGME is worried that providing this information could mislead potential residents or lead them to make faulty assumptions regarding a program, I say it is not for them to decide. They do not extend the same courtesy to us residents. We do not enjoy the same discretion to hide any potential unflattering aspects as do the programs.

In addition to requiring that this information be released publicly, it should be reviewed with each ACGME site visit. The ACGME, of course, does not involve itself with individual resident matters or provide recourse for an aggrieved resident. The intent here would be to have the ACGME review all resident disciplinary action taken by the program for consistency. For this to be feasible, it would require the employment of some type of metric which could allow for comparison. For instance, the electronic evaluation system at my program uses a numerically-based rating system to evaluate trainees in the 6 ACGME core competencies. In addition to being able to view individual evaluations for each rotation, the numerical data compiled from all evaluations submitted to date are presented in aggregate form for each individual core competency and overall. Along with your individual data, the system also reports to each individual trainee, for comparison, the corresponding data for all other residents in the program, both at your respective training level and all levels combined.

Since the core competencies comprise several aspects including medical knowledge, interpersonal communication, and professionalism, grouped under the broader term "clinical competence", it could potentially serve as a useful metric for comparison among trainees. In a system which is entirely subjective, it may be the only objective way for an outside observer to accurately and readily assess the situation. If, during the site visit, the ACGME found inconsistencies, based on the numbers, in those who faced disciplinary action and those who did not, the PD would then be prompted for an adequate explanation. If that explanation was not satisfactory, it could then serve as the impetus for further investigation which could lead to possible censuring, probation, or other adverse accreditation decision. Any action taken by the ACGME would then be required to be made public. This could serve as a possible deterrence against abuse of discretion and might force PDs to consider the ramifications of acting hastily.

With the current apathy displayed by the ACGME, I don't see the system being fair to residents for the foreseeable future. Without a doubt though, there is tremendous room for improvement. The missing key is activism on the part of residents for the reasons already discussed.

In the absence of any true reform, I think it would be great if affected residents had available an independent resource to assist those with a realistic chance of moving forward in transitioning to another program, or, in the case of those with either no realistic chance or desire of continuing in medicine, provide counseling and assistance in transitioning out of medicine and into another career. Of course, this would require both experienced professionals willing to volunteer their time and serve as mentors, as well as philanthropic support for funding, neither of which would be easy to come by. It would provide at least some dignified measure for those residents thrown out by their programs like yesterday's trash without a care as to what will happen to them.

I disagree with your description of anonymous surveys as not being anonymous. Even the ACGME surveys are anonymous....

You're kidding, right? At my semi-annual advisor meeting, I was able to view evaluations which would not ordinarily be viewable to me in the system (e.g. those submitted by senior residents, administrative staff, etc.), and without most of them outing themselves by mentioning details, I was able to easily identify almost all the senior residents by their comments.

 

[wooster201106]

Holy s**t! I didn't realize the post was really that long. Sorry.

 

[residentdoctor]

Since the core competencies comprise several aspects including medical knowledge, interpersonal communication, and professionalism, grouped under the broader term "clinical competence", it could potentially serve as a useful metric for comparison among trainees. In a system which is entirely subjective, it may be the only objective way for an outside observer to accurately and readily assess the situation. If, during the site visit, the ACGME found inconsistencies, based on the numbers, in those who faced disciplinary action and those who did not, the PD would then be prompted for an adequate explanation. If that explanation was not satisfactory, it could then serve as the impetus for further investigation which could lead to possible censuring, probation, or other adverse accreditation decision. Any action taken by the ACGME would then be required to be made public. This could serve as a possible deterrence against abuse of discretion and might force PDs to consider the ramifications of acting hastily.

With the current apathy displayed by the ACGME, I don't see the system being fair to residents for the foreseeable future. Without a doubt though, there is tremendous room for improvement. The missing key is activism on the part of residents for the reasons already discussed.

In the absence of any true reform, I think it would be great if affected residents had available an independent resource to assist those with a realistic chance of moving forward in transitioning to another program, or, in the case of those with either no realistic chance or desire of continuing in medicine, provide counseling and assistance in transitioning out of medicine and into another career. Of course, this would require both experienced professionals willing to volunteer their time and serve as mentors, as well as philanthropic support for funding, neither of which would be easy to come by. It would provide at least some dignified measure for those residents thrown out by their programs like yesterday's trash without a care as to what will happen to them.

well saying, evaluation is so subjective in many resident training. Sometimes, the " terminated resident" just did not get well impressed to the PD and some attendings even no major neglect to patient care and no fail in the exams -- that is most of cases. Why can other program give the " terminated resident" second chance ? after the terminated resident makes effect to improve himself and herself.

 

[ladybuggy]

This is a very interesting topic actually. I have heard so many stories from people. One being terminated due to personality issues (too much conflict with attendings). One claimed they were discriminated against because they were obese. One was terminated because they had a disability.

I think honestly it just boils down to comparability with the residency programs more so than a resident's competence. The environment plays a huge role in the performance of certain types of residents. I honestly do not believe majority of the terminated residents are incompetent whatsoever.

 

[satakay]

I request all Victims to get in touch with each other and start looking for the solution. We must be able to find some solution.
Please share emails and lets start discussing different options through emails.

thanks

My email:
[email protected]

 

[DrMom]

we already have an active thread on this topic. Merging

 

[ForbiddenComma]

I do agree that we need a space where victims of malignant PDs can come together. I am hoping to create such a space.

I realize I was very fortunate in being able to restart my career despite having a bit of a situation. I ran into a clinic that was hiring people like me, and allowed me to get established. The important thing is that while program directors are vastly overpowered in today's GME system... their power is not 100% complete, and there are actually ways of getting around the system.

 

[johnsmithdr11th]

.

 

[johnsmithdr11th]

well saying, evaluation is so subjective in many resident training. Sometimes, the " terminated resident" just did not get well impressed to the PD and some attendings even no major neglect to patient care and no fail in the exams -- that is most of cases. Why can other program give the " terminated resident" second chance ? after the terminated resident makes effect to improve himself and herself.

.

 

[dragonfly99]

Residency, and academic medicine in general, is very political, unfortunately.

I don't agree with the attending on here who says that incompetent residents are not ever passed/promoted and don't get into practice. I think most PD's and faculty try to do their jobs responsibly, but I think it is kind of silly to content that passing of someone with marginal competence (at best) doesn't happen because such a person is charismatic and liked by people. The converse of this is that residents who are medically OK and ethically OK, etc. can be terminated or forced to resign, or just put on probation or threatened, because they have had a bad interaction with the PD or some other faculty member. Sometimes, it is just a personality issue where the resident isn't "liked" by one or more of the faculty. Physicians are just people and they/we are prone to the same biases as everyone else. These biases are how we pick our friends, boyfriends, etc. And these "gut feelings" help me now that I'm out looking for a job - I might take some job that pays less because I like the people I'll be working with or the general atmosphere. I think some of the problems happen because medical students don't really have a lot of information sometimes when they rank programs, and sometimes programs don't have a lot of (or correct) information about applicants.

I don't think some of the changes proposed on here will be or could be made - too expensive, too hard to do logistically, etc. I do wish that being fired or terminated from one residency, or being put on probation, were not SUCH a big deal in all cases. As others have pointed out, it happens in other fields that someone does not do well in a particular job, or isn't a good "fit" with a first job, but the person can quit or be fired and go somewhere else. In residency, if this happens, a lot of the trainees are just screwed, for lack of a better word. And this will become a bigger deal now that people have 200k or 300k med school loans to repay...this isn't the case I don't think in Europe or a lot of other places.

I do think that training more US born med students will help with some of the cultural understanding and language problems that sometimes contribute to IMG's being terminated. Also, just the fact that someone trained in a different medical system abroad as a student is going to make their adjustment to being an intern harder, in most cases. However, I do think it is doubly unfortunate for those types who do get fired who are IMG's. They pretty much gave up a lot, studied hard, took USMLE's, came over here with high hopes of achieving their dream and then got crushed. And these are the people LEAST likely to be able to get a 2nd residency if they get fired.

I think it might help if there was a record kept of the number of terminations and/or resignations in particular programs, going back 5-6 years, and this info should be publicly available (like on FRIEDA). A few residents here or there quitting or being fired could be a bad resident or someone who didn't like taking care of patients, or had a personality disorder that couldn't be fixed, or just people quitting to switch residency fields. Multiple residents/year in the same program would usually be a red flag for med student applicants. It seems unjust that programs have all this info about med students, but students don't have a lot of objective info about programs. What I had when I went to apply was basically word of mouth from faculty @my med school (which, by the way, tends to be very biased and not very fact-based), and snooping around on the residency program's web sites to look at stuff such as where the interns went to med school, what subspecialties they matched into (for IM), what jobs they were in after graduation.

I also think that in cases of remediation or termination, there should be some type of requirement that a resident should have an advocate (preferably someone not very able to be influenced by the PD or dept. chair). This wouldn't be perfect but it might help.

I also think that we should consider having a requirement that a program gives a terminated resident a copy of his/her file from residency, and they should have to provide records in a timely fashion. I know someone who left his program not on great terms (not terminated, but asked to resign after PGY1 and wanted to because he could see the writing on the wall). He had a lot of trouble later getting records of things like documentation of completion of certain rotations even though the program had given him credit for these. It seems like they were dragging their feet just because they could (and disliked him) or just that their department was disorganized. I think it was some of both.

I also think that something that could be done, and should be done, would be to try and survey residents who finished a program within the last 3-5 years. If too expensive to survey them all, then maybe random samples. This would be something like the ACGME survey. I think right now the most honest residents are ones in their last year of training. People are just human beings and most of us are not stupid enough to heavily criticize our program about ANYTHING while we are still a resident there. This is even more true for specialties where people are often going on for MORE training (internal med or maybe general surgery, for example). However, somebody in the last year of derm training or something is more likely to be honest about something bad (attending who doesn't teach, a poorly organized resident clinic, favoritism from the PD, etc.).

 

[mohammad1975]

Well, I resigned from my training at end of second year voluntarily!!! It means that I was fired politely. Residency is like running a political institute. More political you are, better you get along. It is not really about knowledge and graduates not necessarily have knowledge to work independently. It is a big social event that residents are the bottom part of it. Being average is all that you need. A good kissasser, smile all the time like dum people, run the show and sign out with saying some good words and that is it. Feel like home, do not take things seriously, it is a film that resident plays the assistant role (guy which always gets his/her butt kicked and at the end of the day, he/she is happy with th e money he took). It is very simple, go with the flow, abide by the politics of your workplace and be happy. I am not saying it is right, what I am saying is that it is reality. I am applying and hopefully I will get a residency again but my goals, vision in life and perception has changed. This is how it is. Take it or leave it. I am pretty sure that all of us have worked in our native country, how was over there. There were laws and regulations, so the law of this country is like this, so abide with it or go back. Even if i do not get a resdidency and I go back to my native land ,I know what life is all about from now on.

Hopefully I helped ease the tension.

 

[Jewishprincess]

George Washington University, DC - IM, Psychiatry

- At least one of those specialties violated duty hours rules for more than 7 years: all in an effort to make more $$$ for the private doc association.

- NO effort to help residents network or find mentors w/in faculty or w/in the community.
--> As an example: one resident had to find a job via Craigslist.

- GWU attendings, with the exception of one hospitalist, one ED attending, & a smattering of other attendings who are smart enough to stay out of the hierarchy, just don't care and literally take joy in destroying your future if you don't know how to "kiss the ring."

Verdict: extremely malignant, avoid

Although, GWU did teach me to value the nice people in my life. And how to kiss-up to narcissists.

Nobody can be toxic like a shrink. So watch out. Apparently, over the last year or so several residents have been fired and/or prematurely quit from the allegedly extremely-malignant GWU psychiatry program. Might be a rumor, but, having seen what happened to others, supposedly one resident even started recording all conversations and collecting documentation to head off false claims. By report-- he/she got some really interesting stuff. Can't blame him.

It is due to a rather toxic psychiatry PD and no support at all from higher-ups. The acting dean of medicine, Akman, was the psychiatry chairman. He was elevated when the previous dean was fired to get GWU off LCME probation. So expect no help from him if you get crosswise with somebody. Supposedly, this situation is not unique to the psych department.

Anyway, last time around, the GW psychiatry department had to fill several positions in the scramble. Perhaps word has finally gotten out.

GW also only recently got off LCME accreditation probation. If only because they quite blatantly violate ACGME resident hours rules, they may also be in danger of losing some residency program acccreditations too.

However, the real danger is that next time the LCME may simply withdraw accreditation, rather than putting GW on probation. This means everybody, students and residents alike, is SOL. They are already in violation of LCME rules by not even starting to look for a new dean of medicine after 20 months.

 

[furmangrd08]

Baylor - Adult Neurology is malignant, interviews poorly run, interns rude and arrogant to applicants, upper levels uninformed and disinterested in AMGs. Claim to have the best of every neuro subspecialty and lots of funding when in reality they are only strong in NSICU training and are the only program to cover no expenses for applicants. Residents claim workload and didactics/teaching not only unbalanced, but overwhelming yet large majority of residents are IMGs so they may have had no choice where to match compared to AMGs. Witnessed their "Professor Rounds" where an upper level practices their physical exam and history taking technique in front of entire group of peers where the attending teaching was VERY POOR. Do not go to this program if your med school even has a semblance of a Neurology Department as it most assuredly better than Baylor. They may have been an accomplished program in the past, but they have declined.

 

[urgentcase]

deleted

 

[IlDestriero]

With the introduction of the requirement of documented clinical competencies to GME, the pressure for remediation, extension of training and even termination will become the norm. The assumption that essentially everyone can be trained to any field in the standard time is coming to an end. The only Residents that are really at risk are the bottom 10th percentile and the lazy.
Forewarned is forearmed.

 

[NuMD97]

Residency, and academic medicine in general, is very political, unfortunately....

I also think that we should consider having a requirement that a program gives a terminated resident a copy of his/her file from residency, and they should have to provide records in a timely fashion. I know someone who left his program not on great terms (not terminated, but asked to resign after PGY1 and wanted to because he could see the writing on the wall). He had a lot of trouble later getting records of things like documentation of completion of certain rotations even though the program had given him credit for these. It seems like they were dragging their feet just because they could (and disliked him) or just that their department was disorganized. I think it was some of both...

However, somebody in the last year of derm training or something is more likely to be honest about something bad (attending who doesn't teach, a poorly organized resident clinic, favoritism from the PD, etc.).

It's been a very long while since I stopped by these parts, but I received notification today about this thread being updated, and I thought to answer some of the points made here.

There is no question in my mind, that if someone survives beyond first year, completing the second year or close to it, some even entering third year, and then got fired, asked to resign, or however politically correct the terminology may be, and they are made to leave the premises, that something is clearly amiss. I've seen this happen to AMGs as well as IMGs, and no one can convince me that this is not politically charged, and clearly not a question of competency. And before someone jumps on this, I am speaking to those terminated individuals who have not compromised patient care.

The fact that documents are not provided "timely" so that someone can have the opportunity to resurrect their career, as the original poster that I am quoting here suggests, is downright criminal.

Careless words about a program while in residency have cost some literally years before they could get on with their careers in medicine. Was it stupid? Absolutely. Is it deserving of termination? Absolutely not. Are the egos of some of the faculty that weak that they cannot weather criticism about the program? Come on!

Residency is about training. Panels decide who to take into their residency programs based on a certain level of competency. Once committed to a resident it is beholden on the program to educate that resident, using the raw materials s/he has brought to the program. Termination should not be an option if competency is not an issue. Period.

The biggest issue is Medicine cannot govern itself with regard to residency training. Over the years, and decades, several individuals in Congress have seen this issue and attempted to address it [Solarz in NY, being one, who wanted to open up the exams to scrutiny; and Conyers in MI, being another]. If you haven't heard of their work, consider their attempts a failure.

Some residents have managed to hire lawyers and reverse termination, but to do so, one needs an awful lot of money, and it has to be done in federal court not a mock hearing at the level of the program/institution. Most cannot afford to do this, and gamble that they can find another program to resurrect their career. Some are successful doing so. I have watched the careers of some who managed to find another program and are currently directors in their chosen fields. But the years it cost and the emotional expenditure is horrible.

I would love to see some of these programs face public scrutiny for the high handed nature that they run their programs, some like fiefdoms. Without a question in my mind, there needs to be a better system of checks and balances, concerning the way residency programs are run. It would be nice to see it happen in my lifetime.

 

[Peaches1]

Thanks for your incite. Question You say they went on to other fields. Is that because you or they did not want help in getting into similar field/program?
What type of assistance did you provide? Letters of Rec, phone calls, combination or fact specific?
Would your assistance have extended to same field program?

 

[NuMD97]

Thanks for your incite. Question You say they went on to other fields. Is that because you or they did not want help in getting into similar field/program?
What type of assistance did you provide? Letters of Rec, phone calls, combination or fact specific?
Would your assistance have extended to same field program?

Others have noted this in other threads already: Staying in the same specialty can be problematic, because the original program will serve as an impediment to the success of the candidate in the new program. Some manage to successfully explain their situation and can continue, and without citing any statistics [I doubt there are any], the chances of doing that are extremely slim. Sometimes the programs themselves cannot do enough to get you started in a new field. This behooves the resident as well: Starting with a clean slate, with ideally the assistance of faculty that did not agree with the resident's termination, helps bolster the resident when applying elsewhere.

Best of luck.

 

[apg230]

Thanks for your incite. Question You say they went on to other fields. Is that because you or they did not want help in getting into similar field/program?
What type of assistance did you provide? Letters of Rec, phone calls, combination or fact specific?
Would your assistance have extended to same field program?

Just wanted to jump in here and address something that has not yet been mentioned. It seams to me that most of this debate could be obviated by restoring the relationship between the patient and the doctor/resident. I see it like this:

I remember back in medical school I was working on a cardiology service in Chicago and the attending held a little huddle to point out the Family Physician visiting his patient there in the room we just left. He called FP's the most dangerous doctors in medicine and proceeded to blame the patients progressing CHF on the misguided affections of the patient. As a matter of fact the cardiologist told the patient this much but the patient didn't care and stated he loved his doctor, that they went to church together and he still wanted to be under his care regardless of the effectiveness of the treatment approach. WAM! WTF? a patient wanted his own doctor for his own reasons and that was it? So it seems the desire of the patients is what gets left out a lot. But who cares what they think. They don't have medical degrees, its only their care and their bodies.

Call me crazy and old fashioned but the better more humane system is like the one where the apprentice follows a mentor/master for as long as it takes and as long as either are willing. Then you take some exams not unlike steps 1,2,3 and presto new competent, potty trained and properly socialized physician. If your doc doesn't know you can always step outside your comfort zone and go see someone who does and you work it out with that individual. Money barter whatever you figure it out because its the right thing to do. Probably would still be like that if there wasn't so much money being made by all the parasitic appendant bodies to healthcare and medical education. But I digress. Money every time gets in the way. It's on the front and rear of these issues in our system. Sorry for the crazy unhelpful ramble just felt moved by the discussion.

 

[ruralsurg4now]

[Deleted by me.]

 

[MSmentor018]

I think I get it, you want the hospital to take a chunk of the burden too. is airing out the bad laundry going to help residency training?

 

[ruralsurg4now]

[Deleted by me.]

 

[NotAProgDirector]

Absolutely. It's not just "airing bad laundry" any more than letting the residency know that they're talking to a person who failed Step I twice is just "airing bad laundry." There's literally no good justification for why the two entities should not have the same expectations for transparency. Say you were interviewing at a top-flight program that just happened to not mention that they have terminated two residents over the past five years. Don't you think you'd like to know that just as much as the program would like to know if you had been terminated? Making justifications for why a program is different in any way than a resident is merely hypocrisy. Nobody associated with resident training should be ashamed of displaying their records -- if they are, they should be terminated from their post and publicly shamed.

I think we agree more than we disagree.

Somehow my thoughts are not being clearly communicated if you think I'm "angry" about this. Nothing could be farther from the truth. Not promoting or terminating a resident is one of the most difficult things to do in my position -- I feel like a failure, and wonder whether I could have done something to prevent it. Are there crappy PD's out there who create de-facto pyramidal systems by simply failing out a few interns each year? Probably, and I agree they should be removed (or the problem solved).

I also agree that programs should be 100% transparent about how many people did not finish the program, and what happened to them. Not everyone will finish a program and that's not a bad thing, so I'd suggest that not only should programs have to report on how many people didn't finish training, but also what happened to those people. And, it shouldn't be the program that actually reports it but someone else -- probably the ACGME (this minimizes the chances that a program will lie, and allows for standardized reporting). It's actually a great QI project, and would likely be much more useful than the new outcomes/milestones project. Better yet, you could spin it as an "outcome" for programs (since all of the outcomes we're talking about are for trainees).

As far as the comment about whistleblowing, again I fear my meaning did not come through clearly. Everyone should have a chance to whistleblow. My point was simply that I have seen residents who are struggling use "whistleblowing" as a defense. This then creates a never ending cascade of accusations and counter accusations. My point was that this is a really bad situation for everyone, and the truth always gets lost. I spent the rest of that post (on page 4) trying to come up with a better solution. Making non-completers and their reasons public is a great tool I hadn't considered and would fully endorse -- but I don't think that's enough.

I fully agree that the power balance between PD's and residents is out of balance. I'd like to think that in 90+% of situations that PD's are on the up-and-up and that residents can transfer, or get honest assessments of their skills to switch. But that's not based upon any data, just my own rose colored glasses through which I look at the world.

So, maybe we need:

1. A transparent reporting system managed by the ACGME (since they track all training already) that reports the completion rate at all programs. All non completers should be viewable (anonymously), and should report where they went next. Ideally it could include both a statement from the resident and from the PD.

2. A mechanism such that when residents are terminated from programs, that there is some "balanced" reporting on their performance. Clearly any new program needs to know why the resident was terminated, but there should be some statement on their strengths also. Some sort of evaulation file / portfolio should be created and held by a third party.

3. Perhaps some incentive to take residents who had been previously terminated -- whether that's an increased financial incentive, or increased caps, or something else.

Now that I write this, #1 and #2 are actually the same thing. #1 is what's reportable to everyone, and #2 is what's releasable to new programs. All would be managed by the ACGME, but the resident would have some control over what documentation they wanted to include, and wouldn't need to worry that their PD in the future would simply refuse to release documentation. The ACGME could ensure that the slot filled by that resident wasn't available to be filled by another until the file was complete.

 

[MSmentor018]

1. A transparent reporting system managed by the ACGME (since they track all training already) that reports the completion rate at all programs. All non completers should be viewable (anonymously), and should report where they went next. Ideally it could include both a statement from the resident and from the PD.

2. A mechanism such that when residents are terminated from programs, that there is some "balanced" reporting on their performance. Clearly any new program needs to know why the resident was terminated, but there should be some statement on their strengths also. Some sort of evaulation file / portfolio should be created and held by a third party.

3. Perhaps some incentive to take residents who had been previously terminated -- whether that's an increased financial incentive, or increased caps, or something else.

I definitely agree with your post and you've great insight/ideas. although I don't think the agcme will ever release or allow this much transparency. they're suppose to "protect the resident" right? also I don't know if the transferring resident would want anything leaked about what occurred. if leaving on good terms then it's easy but if it's disciplinary action, performance/academic failure...etc that could be embarrassing.

ruralsurg4now-if this was in place would you be comfortable putting your info out there?