ACGME’s role & Malignant Programs

[JusticeMDsMedicine]

After months of perusing this forum, working with resident friends who are dealing with malignant programs it seems to me that the ACGME provides zero or limited guidance, support and accountability in this process.

It seems to me that professionals can invest 10+ years of hardwork and tremoudous sacrifice, unimaginable funds and go into insurmountable debt only to have your whole career hinge and potentially ruined by a PD with a god complex and alternative personal and professional motives. Who oversees the programs? Truly?
I’ve seen tons of ACGME documentation rules, requirements, articles and studies on burnout rates and abuse of resident programs- but when there are actual issues and residents are left hanging high and dry with no alternatives, where is the ACGME? How are they holding the programs accountable ? They seem to provide guidelines but no support. Residents are terrified to be blacklisted. Why do they exist? What role do they in fact play? How are they letting these malignant programs not only jeopardize the careers of dedicated professionals but ultimately are the ones churning out doctors whose training could potentially not meet basic health care standards.
Is healthcare in our country broken from inception?

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[GoSpursGo]

The ACGME has some power, but most of the time it really doesn't benefit current residents--if you make noise and get your own program on probation or even closed, that's obviously a bad situation for you.

There's also a fine line between "difficult" and "malignant." Nobody likes working 80 hour weeks with 4 days off in a month, but at the same time the only way you learn to take care of patients is putting in the hours--nobody wants to spend 3-7 years training and then not be able to pass their board exams, or worse, actually be a danger taking care of patients. From the outside, determining where that line gets crossed to be truly malignant is difficult to tell.

 

[Mass Effect]

A lot of times, it's not that the program is malignant. It's that the resident is a problem. Just another side to consider.

 

[Dave1980]

A lot of times, it's not that the program is malignant. It's that the resident is a problem. Just another side to consider.

This 100%.

Attached is a link to a resident who claims she was fired for having cancer:

WAGGEL v. GEORGE WASHINGTON UNIVERSITY, No. 1:2016cv01412 - Document 48 (D.D.C. 2018)

WAGGEL v. GEORGE WASHINGTON UNIVERSITY, No. 1:2016cv01412 - Document 48 (D.D.C. 2018) case opinion from the District of Columbia US Federal District Court

law.justia.com

 

[Mass Effect]

It's the people in the program....not the self usually.

Assuming this is sarcasm?

 

[Mass Effect]

I said, "not-self usually." No sarcasm intended. There are malignant programs made up of malignant people.

Most programs/people aren't malignant. I maintain, a lot of times, there are problem residents with poor insight who complain of malignancy within their program.

 

[Arcan57]

Nope. I've seen several programs where malignant attendings exist, residents who spread rumors about other residents, etc.

The plural of anecdote isn’t data.

 

[deleted480308]

After months of perusing this forum, working with resident friends who are dealing with malignant programs it seems to me that the ACGME provides zero or limited guidance, support and accountability in this process.

It seems to me that professionals can invest 10+ years of hardwork and tremoudous sacrifice, unimaginable funds and go into insurmountable debt only to have your whole career hinge and potentially ruined by a PD with a god complex and alternative personal and professional motives. Who oversees the programs? Truly?
I’ve seen tons of ACGME documentation rules, requirements, articles and studies on burnout rates and abuse of resident programs- but when there are actual issues and residents are left hanging high and dry with no alternatives, where is the ACGME? How are they holding the programs accountable ? They seem to provide guidelines but no support. Residents are terrified to be blacklisted. Why do they exist? What role do they in fact play? How are they letting these malignant programs not only jeopardize the careers of dedicated professionals but ultimately are the ones churning out doctors whose training could potentially not meet basic health care standards.
Is healthcare in our country broken from inception?

If that’s your photo, I would use something not identifiable while rallying up a fight against your program.

 

[Goro]

This 100%.

Attached is a link to a resident who claims she was fired for having cancer:

WAGGEL v. GEORGE WASHINGTON UNIVERSITY, No. 1:2016cv01412 - Document 48 (D.D.C. 2018)

WAGGEL v. GEORGE WASHINGTON UNIVERSITY, No. 1:2016cv01412 - Document 48 (D.D.C. 2018) case opinion from the District of Columbia US Federal District Court

law.justia.com

My understanding was that this resident was fired for being unteachable, and the cancer angle was a front.

 

[Dave1980]

My understanding was that this resident was fired for being unteachable, and the cancer angle was a front.

That was my point. She said she was fired for "having cancer" and sued the program. Sounds like a malignant program!

Then you find out she is f*cking crazy and was given many, many chances to get her act together but couldn't. In my experience someone who is having issues at a program and calls it malignant is usually the problem.

Reminds me of the saying: "If you go through life and everyone is an a**hole, you're the a**hole."

 

[Mass Effect]

Nope. I've seen several programs where malignant attendings exist, residents who spread rumors about other residents, etc.

Of course malignant PEOPLE exist. But a malignant attending doesn't make a malignant program. A malignant resident doesn't make a malignant program. Usually, it's a problem resident complaining of a malignant program without realizing he/she is the problem. There are toxic personalities in most residencies, just as there are toxic personalities in most workplaces in general, in most schools, in most communities. But a few toxic personalities doesn't make the program malignant.

But still, malignant programs exist. When a program identifies a "problem resident," all hell will break loose until that said resident is fired.

Usually, there's a good reason for the resident to be identified as a "problem resident." And actually, it's usually that resident raising the flag on malignancy.

My understanding was that this resident was fired for being unteachable, and the cancer angle was a front.

There were a host of reasons she was fired, including being unteachable. She also made a number of mistakes - missing shifts, solo hands-on restraint, etc.

 

[Mass Effect]

What if she was given the proper guidance?

Did you read the court documents? She was given proper guidance about a dozen times.

 

[CidHighwind]

What I never got about these cases is why sue to get back into the program? Even if that person won, they would essentially be going into a hostile working environment that doesn’t want them.

 

[CidHighwind]

That’s one of my worries as I am getting ready to apply to residency. You don’t really want to go someplace that has the tendancy of firing residents. I get that not every resident is good, but IMO if the resident was good enough to get through medical school, then not being able to get that resident up to speed is kind of a failure of the program, since the whole point of it is that they’re able to train you to be a good doctor. It’s easy to blame the resident, but at the same time if a program has a tendency of people being fired or transferring out, that’s not a place I want to be.

 

[rokshana]

Exactly! That is the point other people fail to understand in this forum. "Always blame the problem resident" is a faulty assumption that needs to be fixed with any program.

I suspect neither one of you have completed a residency...

 

[Mass Effect]

That’s one of my worries as I am getting ready to apply to residency. You don’t really want to go someplace that has the tendancy of firing residents. I get that not every resident is good, but IMO if the resident was good enough to get through medical school, then not being able to get that resident up to speed is kind of a failure of the program, since the whole point of it is that they’re able to train you to be a good doctor. It’s easy to blame the resident, but at the same time if a program has a tendency of people being fired or transferring out, that’s not a place I want to be

Nine times out of ten, it's not about being unable to get the resident "up to speed." Most terminations are due to professionalism issues. Did you read the court documents posted above about Stephanie Waggel? You should read those and you'll see what we're talking about.

Exactly! That is the point other people fail to understand in this forum. "Always blame the problem resident" is a faulty assumption that needs to be fixed with any program.

I think it's terribly presumptuous to assume that because people don't agree with you, it's because we "fail to understand" something. I, for one, don't always blame the "problem resident." But this forum is littered with accounts from "problem residents" who, it turns out, were mostly to blame for their own troubles during residency. Look up some of the threads and you'll see how the stories evolve. It starts with "my program targeted me from day one" and then it turns out, as the thread goes on, we find out on page 7 that the resident failed Step 3, failed their in-training exam, missed shifts without calling in, failed a remediation, threatened a nurse, and told off an attending. And he/she has little to no insight that he/she is to blame for his/her own problems. This is what we mean by the "problem resident" being to blame. We fully acknowledge that some programs aren't rainbows and butterflies, but more often than not it's the other way around.

Most people went into residency thinking like you. We all worked so hard, sacrificed so much to get where we are that we can't imagine anything bad enough that would cost someone their livelihood after all that. Then we see it. Once you see what a problem resident really is, you'll sing a different tune.

 

[Apollyon]

People that struggle with college, then, somehow, get into med school struggle in med school. These same people struggle in residency, and, if they make it through, wonder why every day in practice is, well, a struggle.

As someone else said on SDN today or yesterday, paraphrased, "When everyone else has the problem, you have the problem".

 

[CidHighwind]

Nine times out of ten, it's not about being unable to get the resident "up to speed." Most terminations are due to professionalism issues. Did you read the court documents posted above about Stephanie Waggel? You should read those and you'll see what we're talking about.



I think it's terribly presumptuous to assume that because people don't agree with you, it's because we "fail to understand" something. I, for one, don't always blame the "problem resident." But this forum is littered with accounts from "problem residents" who, it turns out, were mostly to blame for their own troubles during residency. Look up some of the threads and you'll see how the stories evolve. It starts with "my program targeted me from day one" and then it turns out, as the thread goes on, we find out on page 7 that the resident failed Step 3, failed their in-training exam, missed shifts without calling in, failed a remediation, threatened a nurse, and told off an attending. And he/she has little to no insight that he/she is to blame for his/her own problems. This is what we mean by the "problem resident" being to blame. We fully acknowledge that some programs aren't rainbows and butterflies, but more often than not it's the other way around.

Most people went into residency thinking like you. We all worked so hard, sacrificed so much to get where we are that we can't imagine anything bad enough that would cost someone their livelihood after all that. Then we see it. Once you see what a problem resident really is, you'll sing a different tune.

I mean, you’re probably right, but I’ve definitely heard of residents being told that they weren’t “cut out” for that specialty and that it’s best if they go into something else. It wasn’t that they were bad people or didn’t try, just that that program/specialty wasn’t a fit. Now obviously I’m on the outside looking in, and maybe there is more to the story, but I’m not convinced that it’s always 100% on the resident 0% on the program.

 

[Mass Effect]

I mean, you’re probably right, but I’ve definitely heard of residents being told that they weren’t “cut out” for that specialty and that it’s best if they go into something else. It wasn’t that they were bad people or didn’t try, just that that program/specialty wasn’t a fit. Now obviously I’m on the outside looking in, and maybe there is more to the story, but I’m not convinced that it’s always 100% on the resident 0% on the program.

Yes, that's true. What's your point though? There are a lot of people out there who will tell you straight up that their first residency was a poor fit. Sometimes that's because they matched through SOAP and ended up in a specialty they didn't like. Other times, it was a specialty they liked but they weren't good at it. One of my friends from med school ended up in surgery and both he and the program realized pretty soon in intern year he wasn't cut out to be a surgeon. Even he will tell you that. Another one was in psych and after intern year, switched because she realized she didn't like it. A program or specialty being a poor fit has nothing to do with what this thread is about, which is malignant programs versus problem residents. I think that because you're not a resident yet, you likely haven't had exposure to this stuff yet, but when we say problem resident, we're not talking about residents who are in a poor fit program. That term is used to describe residents who are truly a problem, either because of their poor knowledge (which is rare), unprofessionalism, poor attitude, or toxicity.

 

[Arcan57]

(1) But still, malignant programs exist. (2) When a program identifies a "problem resident," all hell will break loose until that said resident is fired.

You're inferring a lot of suppositions that aren't as on the nose as you'd like them to be if you feel that sentence 1 and sentence 2 support each other.

It's possible as a thought exercise to construct a program that is filled with malignant people that want to ruin trainees simply because they get satisfaction from crushing someone. This is the starting assumption for many "problem" residents who are not burdened with self-awareness that post on this forum. While such a program might exist, there are a lot of forces that conspire against that being the norm. Most physicians aren't sociopaths, most physicians that go into academics take a cut in pay at least in part because they want to be involved in training residents, and losing a resident is a huge PITA for everyone involved.

Very few residencies are big enough to have the luxury perfusion to fire a resident just for grins. The ones that are big enough to lose a resident without painful changes are generally going to have too many attendings involved for them all to be sociopaths. Personality conflicts do happen and there are definitely residents that end up not fitting the culture of the institution. Most trainees when dealing with a personality conflict involving huge discrepancies in power adopt a "head down, this is temporary" stance. Very rarely that's going to allow systemic abuses to go unchallenged, so it's not a perfect strategy. Other trainees decide to go to war over personality conflicts either out of ego or a rigid sense of justice. They read their institution's policies that support their stance while conveniently ignoring the relevant sections that address the consequences of their failings. They'll point out the one attending that says they're doing ok and ignore the 4-5 that told them they had significant areas that needed to improve. It's possible that SDN is just a hopelessly skewed sampling, but in instances where there has been a relatively comprehensive description of the situation it's vanishingly rare that I'll finish reading the thread and not think "I'd have fired/allowed to transfer/non-renewed them too."

 

[Arcan57]

That’s one of my worries as I am getting ready to apply to residency. You don’t really want to go someplace that has the tendancy of firing residents. I get that not every resident is good, but IMO if the resident was good enough to get through medical school, then not being able to get that resident up to speed is kind of a failure of the program, since the whole point of it is that they’re able to train you to be a good doctor. It’s easy to blame the resident, but at the same time if a program has a tendency of people being fired or transferring out, that’s not a place I want to be.

Med school /= residency. If you were intelligent enough to get into medical school, follow the rules, and are willing to put the time in then you'll graduate as a doctor. The traits required to make it through medical school are only a subset of the traits required in residency. Executive functioning, interpersonal skills, and tolerance for ambiguity are critical in residency in a way they just aren't in med school. Ideally, medical school would emphasize these traits in a explicit way. Back when medical students where an integral part of the academic team, this reinforcement was more common. Medicare billing rules and the rise of the EMR have shunted med students (especially M3s) almost exclusively into an observer role. Subsequently, deficiencies in those 3 core traits are not as noticeable and there is less incentive to correct them. I had a fellow student that didn't like his OB rotation and so would write his postpartum notes in crayon (back in the days of paper charts). He still got a B in the rotation because getting a C required convening a special committee. Assuming that particular incident didn't make it into their SLOR, who's at fault if his residency finds him to be unable to advance at an appropriate pace in his training?

Medical schools prize completion of their curricula as the overriding goal. As long as you graduate, you go down as a win in their books. Residency is charged with making you a physician that can practice independently in their specialty. It's a much higher bar and the tools that residencies have to ensure the initial quality of their trainees are so much less accurate then those for entry into medical school.

 

[Goro]

Nine times out of ten, it's not about being unable to get the resident "up to speed." Most terminations are due to professionalism issues. Did you read the court documents posted above about Stephanie Waggel? You should read those and you'll see what we're talking about.

I think it's terribly presumptuous to assume that because people don't agree with you, it's because we "fail to understand" something. I, for one, don't always blame the "problem resident." But this forum is littered with accounts from "problem residents" who, it turns out, were mostly to blame for their own troubles during residency. Look up some of the threads and you'll see how the stories evolve. It starts with "my program targeted me from day one" and then it turns out, as the thread goes on, we find out on page 7 that the resident failed Step 3, failed their in-training exam, missed shifts without calling in, failed a remediation, threatened a nurse, and told off an attending. And he/she has little to no insight that he/she is to blame for his/her own problems. This is what we mean by the "problem resident" being to blame. We fully acknowledge that some programs aren't rainbows and butterflies, but more often than not it's the other way around.

Indeed. Tip of the iceberg syndrome is a thing.

 

[CidHighwind]

Med school /= residency. If you were intelligent enough to get into medical school, follow the rules, and are willing to put the time in then you'll graduate as a doctor. The traits required to make it through medical school are only a subset of the traits required in residency. Executive functioning, interpersonal skills, and tolerance for ambiguity are critical in residency in a way they just aren't in med school. Ideally, medical school would emphasize these traits in a explicit way. Back when medical students where an integral part of the academic team, this reinforcement was more common. Medicare billing rules and the rise of the EMR have shunted med students (especially M3s) almost exclusively into an observer role. Subsequently, deficiencies in those 3 core traits are not as noticeable and there is less incentive to correct them. I had a fellow student that didn't like his OB rotation and so would write his postpartum notes in crayon (back in the days of paper charts). He still got a B in the rotation because getting a C required convening a special committee. Assuming that particular incident didn't make it into their SLOR, who's at fault if his residency finds him to be unable to advance at an appropriate pace in his training?

Medical schools prize completion of their curricula as the overriding goal. As long as you graduate, you go down as a win in their books. Residency is charged with making you a physician that can practice independently in their specialty. It's a much higher bar and the tools that residencies have to ensure the initial quality of their trainees are so much less accurate then those for entry into medical school.

In that case, doesn’t at least some of the blame fall onto the medical school? If the point of clinical rotations is to get the student ready for residency, then the fact that they graduate someone grossly unprepared to do the job is unfortunate. At my school they started having us doing H&Ps and presentations as M1s since there were too many people that got on wards as M3s and didn’t have those basic skills.

Yes, that's true. What's your point though? There are a lot of people out there who will tell you straight up that their first residency was a poor fit. Sometimes that's because they matched through SOAP and ended up in a specialty they didn't like. Other times, it was a specialty they liked but they weren't good at it. One of my friends from med school ended up in surgery and both he and the program realized pretty soon in intern year he wasn't cut out to be a surgeon. Even he will tell you that. Another one was in psych and after intern year, switched because she realized she didn't like it. A program or specialty being a poor fit has nothing to do with what this thread is about, which is malignant programs versus problem residents. I think that because you're not a resident yet, you likely haven't had exposure to this stuff yet, but when we say problem resident, we're not talking about residents who are in a poor fit program. That term is used to describe residents who are truly a problem, either because of their poor knowledge (which is rare), unprofessionalism, poor attitude, or toxicity.

I guess my point is that even if it’s a specialty that someone isn’t “good at” like surgery, then ideally the residency should be able to coach up and graduate someone if they’re truly committed to that specialty. It’s kind of funny because when students on here wonder whether they would be a good fit for a certain specialty everyone just tells them “do what you love” or “the point of residency is to train you to do whatever”. IDK, maybe it’d be better for everyone and were real with people and say that maybe they shouldn’t go into surgery if gore makes them queasy or they can’t stand for hours at a time, or that if they’re not exactly a “people person” a primary care specialty may not be a good fit, etc.

 

[deleted480308]

Blame both the residency and the medical school then. End of story.

Or maybe, just maybe, if a bunch of people want to fire a resident in a situation where it objectively means more work for all of those staying....they are justified in firing the resident

 

[Arcan57]

In that case, doesn’t at least some of the blame fall onto the medical school? If the point of clinical rotations is to get the student ready for residency, then the fact that they graduate someone grossly unprepared to do the job is unfortunate. At my school they started having us doing H&Ps and presentations as M1s since there were too many people that got on wards as M3s and didn’t have those basic skills.

Sure the medical schools may be to blame in some cases. Also, the med student that firmly refused to go through any sort of personal growth and did the bare minimum required to graduate may bear some responsibility also.

 

[Mass Effect]

I guess my point is that even if it’s a specialty that someone isn’t “good at” like surgery, then ideally the residency should be able to coach up and graduate someone if they’re truly committed to that specialty. It’s kind of funny because when students on here wonder whether they would be a good fit for a certain specialty everyone just tells them “do what you love” or “the point of residency is to train you to do whatever”. IDK, maybe it’d be better for everyone and were real with people and say that maybe they shouldn’t go into surgery if gore makes them queasy or they can’t stand for hours at a time, or that if they’re not exactly a “people person” a primary care specialty may not be a good fit, etc.

What?? Residencies aren't there to "coach" someone up when they're not good at the specialty. You can't be a surgeon if you can't hack surgical skills. That's on you to develop and if you don't have the dexterity, there's nothing your program can do. You can't be a psychiatrist if you don't like talking to patients. The residency program isn't going to change that in you. You can't be an orthopod if you don't like bones. You can't be a radiologist if you hate dark rooms. You can't be a neurologist if you can't learn neuroanatomy. None of this is the program's fault. That's like saying it's your undergrad's fault if you fail to get into med school. The residency program should NOT graduate a surgery resident who can't suture just because he/she is "committed" to surgery. This isn't grade school. Participation trophies in the medical specialties have life and death consequences.

Also, you're misunderstanding the forum. I have yet to see people tell a poster "do what you love" when it comes to a poster not having the skills for a particular specialty. What you see is posters saying "do what you love" when a poster is debating going into FM when they want to make half a million a year or a poster debating going into psych when their family wants them to be a neurosurgeon. You never see a poster say anything even remotely similar to "you'd suck at this specialty, but do what you love anyway." That isn't how it works and I haven't seen anyone here pretend otherwise.

Blame both the residency and the medical school then. End of story.

Only if you're an entitled snowflake who refuses to take responsibility for your own shortcomings. You can't always blame others because you didn't get what you want. At some point, personal responsibility must play a role.

 

[CidHighwind]

Sure the medical schools may be to blame in some cases. Also, the med student that firmly refused to go through any sort of personal growth and did the bare minimum required to graduate may bear some responsibility also.

I mean that’s the thing right, the “bare minimum to graduate” should still be a level where they should be able to complete residency. If people are graduating medical school and just flat out suck once they get into residency, the requirements to graduate medical school need to be raised. It sounds like I’m defending the residents but I’m really not. You can’t force someone to improve if they don’t want to. That said, there’s always things that medical educators can improve upon in our medical school training to either get people to a competent level for residency or weed out those that are “uncoachable”.

 

[Mass Effect]

I mean that’s the thing right, the “bare minimum to graduate” should still be a level where they should be able to complete residency. If people are graduating medical school and just flat out suck once they get into residency, the requirements to graduate medical school need to be raised. It sounds like I’m defending the residents but I’m really not. You can’t force someone to improve if they don’t want to. That said, there’s always things that medical educators can improve upon in our medical school training to either get people to a competent level for residency or weed out those that are “uncoachable”.

I think you're way too early in your training to really understand this. Wait until you're in residency and you'll see how sometimes people get through who likely shouldn't and it's not the med school's fault either. There are hot messes out there who are good at hiding it or who keep it under control until they're in residency and for some reason, they feel like they can go wild and not worry about their reputation (see Eugene Gu). Sometimes, they have a lapse of judgment (see Thersia Knapik) or do something incredibly stupid (see Anjali Ramkissoon). In none of these cases was their med school or their residency at fault.

 

[rokshana]

In that case, doesn’t at least some of the blame fall onto the medical school? maybe it’d be better for everyone and were real with people and say that maybe they shouldn’t go into surgery if gore makes them queasy or they can’t stand for hours at a time, or that if they’re not exactly a “people person” a primary care specialty may not be a good fit, etc.

If you can’t figure that out without someone actually having tell you...then maybe you shouldn’t have gotten into med school in the first place

Always looking for someone else to blame... this is the problem...there will be people that managed to get through things by the skin of their teeth...and when they finally hit the wall, it’s someone else’s fault...personal responsibility is quickly getting lost...

 

[rokshana]

I mean that’s the thing right, the “bare minimum to graduate” should still be a level where they should be able to complete residency. If people are graduating medical school and just flat out suck once they get into residency, the requirements to graduate medical school need to be raised. It sounds like I’m defending the residents but I’m really not. You can’t force someone to improve if they don’t want to. That said, there’s always things that medical educators can improve upon in our medical school training to either get people to a competent level for residency or weed out those that are “uncoachable”.

There is nothing that really prepares you to be an intern except for being an intern...there is nothing that really prepares you to be a resident except for being a resident, and nothing prepares you for being an attending except for being an attending...the common thread? You need experience and the ability to adapt...there are plenty of people in med school that are brilliant and should succeed in residency...on paper...but can’t adapt to the change of being in med school to being a resident...easy enough in many places to hide in med school that these deficiencies don’t get attention...

Conversely, there are people who were terrible students and blossom as residents...one of my best friends fall in this category...failed his steps , lucked out on match when he only had 2 interviews...went on to be chief resident and did fellowship at a fairly prestigious program...I wouldn’t hesitate in him taking care of my children...

 

[Raryn]

I think you're way too early in your training to really understand this. Wait until you're in residency and you'll see how sometimes people get through who likely shouldn't and it's not the med school's fault either. There are hot messes out there who are good at hiding it or who keep it under control until they're in residency and for some reason, they feel like they can go wild and not worry about their reputation (see Eugene Gu). Sometimes, they have a lapse of judgment (see Thersia Knapik) or do something incredibly stupid (see Anjali Ramkissoon). In none of these cases was their med school or their residency at fault.

Oooo, hadn't heard that one before. Wonder how I missed it.

 

[GoSpursGo]

Ok....we can all agree to disagree then. It is everyone's fault.

Maybe everyone shares some amount of "fault," if that makes you feel better, but this isn't junior high--if you're in your late 20s/early 30s and you fail to meet the requirements that are asked of you, then the lion's share of the blame falls squarely on your own shoulders.

 

[OrthoTraumaMD]

Ok....we can all agree to disagree then. It is everyone's fault.

Residency is a job. If you get fired for incompetence, no one owes you anything. No one is owed a job. The blame rests with you unless you can prove otherwise. End of story.

 

[BoardingDoc]

Oooo, hadn't heard that one before. Wonder how I missed it.

There's even more details here. That's impressively stupid and petty behavior.

It looks like she got fired in 2012 but then managed to get a job in Arizona and somehow used that as a way of completing her surgery residency AND start a critical care fellowship. The ABS says she's board certified in general surgery and in CC, but the recert date for CC is this year? Still, looks like she managed to dig herself out of that hole.

Thersia Knapik, MD - 2018-2019 | College of Medicine - Tucson

medicine.arizona.edu

 

[Mass Effect]

Oooo, hadn't heard that one before. Wonder how I missed it.

Yeah, it was discussed on SDN back in 2012 when it actually happened.

There's even more details here. That's impressively stupid and petty behavior.

Yes, it was, but we should also note that her program also broke protocol in the way they not only fired her, but had her fellowship rescinded before she even initiated the grievance/appeal process.

 

[Goro]

There's even more details here. That's impressively stupid and petty behavior.

It looks like she got fired in 2012 but then managed to get a job in Arizona and somehow used that as a way of completing her surgery residency AND start a critical care fellowship. The ABS says she's board certified in general surgery and in CC, but the recert date for CC is this year? Still, looks like she managed to dig herself out of that hole.

Thersia Knapik, MD - 2018-2019 | College of Medicine - Tucson

medicine.arizona.edu

The citations in the decision reveal some fascinating cases of resident firings:

Fenje v. Feld, 398 F.3d 620 | Casetext Search + Citator

Read Fenje v. Feld, 398 F.3d 620, see flags on bad law, and search Casetext’s comprehensive legal database

casetext.com

Shaboon v. Duncan, 252 F.3d 722 | Casetext Search + Citator

Read Shaboon v. Duncan, 252 F.3d 722, see flags on bad law, and search Casetext’s comprehensive legal database

casetext.com

Gupta v. New Britain General Hospital, 239 Conn. 574 | Casetext Search + Citator

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Hernandez v. Overlook Hosp, 149 N.J. 68 | Casetext Search + Citator

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[Raryn]

The citations in the decision reveal some fascinating cases of resident firings:

Fenje v. Feld, 398 F.3d 620 | Casetext Search + Citator

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Shaboon v. Duncan, 252 F.3d 722 | Casetext Search + Citator

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Gupta v. New Britain General Hospital, 239 Conn. 574 | Casetext Search + Citator

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Hernandez v. Overlook Hosp, 149 N.J. 68 | Casetext Search + Citator

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Ross v. University of Minnesota, 439 N.W.2d 28 | Casetext Search + Citator

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Gul v. Center for Family Medicine, 762 N.W.2d 629 | Casetext Search + Citator

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Board of Curators, Univ. of Mo. v. Horowitz, 435 U.S. 78 | Casetext Search + Citator

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Anyone with more time than me want to give me the highlights?

 

[a2d24g]

This thread has gone off the rails... Yes, there are definitely nutcase residents who try malign their program and be a victim. These people almost always lose in court, lose their positions, and lose their careers. But there are also several instances and court cases of PD/attendings who are also nutcases yet retain their jobs without serious repercussions. (OSU urology PD "Who's your daddy" and Rutgers anesthesia sexual harassment)

But... to bring this back on track and share my two cents.
The ACGME has no role in helping residents with malignant programs, illegal interview questions, match violations etc. I'm also not too keen on the label "malignant programs," but that's a different discussion. As a medical student back several years ago, I recall our dean having a specific lecture for M4s titled "How to handle illegal questions." The basic idea was to redirect, answer vaguely, or as a last resort report the program but nothing will likely happen. The balance of power is horribly shifted towards programs and against residents/medical students.

I reported nepotism in my residency program to ACGME, but I wasn't a crazy off the wall resident. I was a well liked resident. I liked my coresidents. And I even liked my PD. But, my PD had accepted multiple family members to our residency program. All the family members were decent, but they had the lowest step scores in the program, and were no where near the top candidates. I felt it was dishonest to advertise X number of spots in the match, when the reality was X-#family members needing a position. (I'm also not a fan of step scores for ranking applicants, but that was part of the program's ranking process.) We had several great visiting students who ended up ranked below the family members. When the resident members of interview committee pointed this out to our APD, he acknowledged the issue. And that's all. As residents, and perhaps even the APD, we realized it was risky to press the matter further as our PD was well connected in the field. We reported this to ACGME who gave us a rectal tube's worth of C. Dif advice about open lines of communication and suggestions for how to address the matter with the PD. In the end they said it was an internal affair and that they could not address the issue.

Silver lining: It was during that time I learned nepotism wasn't illegal in the US. I think it's only illegal in public office. Unfair? sure. Inappropriate? I guess maybe.

My main beef back then was the fact that we were a competitive specialty that wasn't giving a lot of hard working applicants a shot. Looking back, I'm still not sure. The family members were Ok but not amazing. But in general, so are most residents.

 

[OrthoTraumaMD]

This thread has gone off the rails... Yes, there are definitely nutcase residents who try malign their program and be a victim. These people almost always lose in court, lose their positions, and lose their careers. But there are also several instances and court cases of PD/attendings who are also nutcases yet retain their jobs without serious repercussions. (OSU urology PD "Who's your daddy" and Rutgers anesthesia sexual harassment)

But... to bring this back on track and share my two cents.
The ACGME has no role in helping residents with malignant programs, illegal interview questions, match violations etc. I'm also not too keen on the label "malignant programs," but that's a different discussion. As a medical student back several years ago, I recall our dean having a specific lecture for M4s titled "How to handle illegal questions." The basic idea was to redirect, answer vaguely, or as a last resort report the program but nothing will likely happen. The balance of power is horribly shifted towards programs and against residents/medical students.

I reported nepotism in my residency program to ACGME, but I wasn't a crazy off the wall resident. I was a well liked resident. I liked my coresidents. And I even liked my PD. But, my PD had accepted multiple family members to our residency program. All the family members were decent, but they had the lowest step scores in the program, and were no where near the top candidates. I felt it was dishonest to advertise X number of spots in the match, when the reality was X-#family members needing a position. (I'm also not a fan of step scores for ranking applicants, but that was part of the program's ranking process.) We had several great visiting students who ended up ranked below the family members. When the resident members of interview committee pointed this out to our APD, he acknowledged the issue. And that's all. As residents, and perhaps even the APD, we realized it was risky to press the matter further as our PD was well connected in the field. We reported this to ACGME who gave us a rectal tube's worth of C. Dif advice about open lines of communication and suggestions for how to address the matter with the PD. In the end they said it was an internal affair and that they could not address the issue.

Silver lining: It was during that time I learned nepotism wasn't illegal in the US. I think it's only illegal in public office. Unfair? sure. Inappropriate? I guess maybe.

My main beef back then was the fact that we were a competitive specialty that wasn't giving a lot of hard working applicants a shot. Looking back, I'm still not sure. The family members were Ok but not amazing. But in general, so are most residents.

I was so appalled by the urology PD case that I read the entire 30 page court decision. (I’m assuming you are talking about the guy who threatened residents and didn’t allow them to sit for boards the day before) It was one of the most horrific abuses of power I have ever seen.

 

[Mass Effect]

And this is why you don’t share personal stuff with “friends.” This sort of b*tchy petty behavior is unfortunately common. Gives female surgeons a bad name— I have personally witnessed two other similar incidents (and know of a third) where a female resident attempted to undermine another female resident for no other reason than pure personal/revenge. And this sociopath in the article still somehow got to practice medicine. She should never have been allowed to set foot in a hospital again. If she is like this with a “friend” who wronged her, imagine what she does behind closed doors.

Completely agree. Even if she felt wronged by her colleague, there's just no excuse to send a letter to her fellowship. It's a shame she never acknowledged how wrong her actions were.

That said, if you think she's a sociopath, check out what happened to the doc involved in the Ross vs. the University of MN case cited below. Reader's Digest version: he allegedly impregnated a patient, harassed people, posted the name, address, and phone number of a woman online (and impersonated her), prescribed meds to colleagues who weren't patients, and has a criminal history he didn't disclose. It's crazy.

A 'serious threat,' doctor suspended

Nearly a year after being fired by the Center for Health and Human Services, a psychiatrist who had sex with patients, illegally prescribed drugs to co-

www.southcoasttoday.com

 

[Dr.LeoSpaceman]

My main beef back then was the fact that we were a competitive specialty that wasn't giving a lot of hard working applicants a shot. Looking back, I'm still not sure. The family members were Ok but not amazing. But in general, so are most residents.

What did you expect the ACGME to do? Their role is not to instruct programs on precise selection criteria. If you have a problem with this, your beef isn't with the ACGME it's with the hospital system/department allowing it to happen. In the end, I see little room between nepotism and "courtesy selections" for people who worked in a faculty member's lab, or programs that prefer internal applicants.

I can say from personal experience within the past 2 years that the ACGME takes allegations of abuse incredibly seriously, and their involvement when it happens isn't taken lightly by GME offices. But no, I'm not surprised when you get platitudes for a "life isn't fair" report.

 

[dannyboy1]

Every residency class will have at least one “weak” resident. Many (most?) will just pass them through. The ones that don’t get labeled as malignant.....

 

[Mass Effect]

Every residency class will have at least one “weak” resident.

That hasn't been my experience at all, but I guess it depends on your definition of weak.

 

[VA Hopeful Dr]

That hasn't been my experience at all, but I guess it depends on your definition of weak.

I mean, every class has to have the one resident who is weaker than all the others. But that one could still be plenty competent.

 

[Mass Effect]

I mean, every class has to have the one resident who is weaker than all the others. But that one could still be plenty competent.

Right. Take a residency class of 10 people. Obviously, one person is the strongest and one person is the least strongest/weakest, but even the weakest isn't necessarily "weak."

 

[dannyboy1]

Right. Take a residency class of 10 people. Obviously, one person is the strongest and one person is the least strongest/weakest, but even the weakest isn't necessarily "weak."

Yes. But frequently there is at least one resident whose abilities are questionable at best (you will likely find this person in larger, non competitive specialties like IM FM PEDS ). The point is that most of them will end up graduating. ( couple of reasons for this, it really takes a heart of stone to torpedo someone’s career, also it makes very little sense from an economic and legal point of view to fire a worker who is underpaid and is also just a temporary employee anyways)

 

[Mass Effect]

The issue is that residency is only a job when its convenient for the residency.

When a residency wants to fire employees at will, or to ignore title IX, or to take the narrowest possible view of what constitutes a 'reasonable' disability accommodation, well then they're a job.

On the other hand a residency is an educational program when it wants to collude with other residencies during the match, or when they want to give detailed lists of fired residents' deficiencies to other residencies that might hire them. They are also educators when they demand that the government subsidize 100% of their employees salaries and tuition, or when they want to tie completion of their programs to government mandated licensure.

Jobs are kept fair and safe primarily through free market competition. Education is kept fair and safe primarily through government oversight. Both systems of accountability have strengths and weaknesses, but either is preferable to a system that has no accountability at all.

You have a point in general, but in this particular thread, I'd argue that it doesn't matter whether you'd consider residency a job or an educational entity. The point is, if you're unqualified for it, no one owes you anything. People are dismissed from college when they can't make the grade. The college is under no obligation to push them through. Same for med school. To expect there to be a different standard for residency where another poster has said it's the fault of the program when a resident can't progress is BS. In very rare cases, a resident may be in a malignant program in which this happens, but in the majority of cases, the failure to meet milestones/minimal standards of competency is the fault of the resident's.

 

[hallowmann]

I think there are signs that there is something more to the program than to the resident. A single resident every 3 yrs being removed is hardly a sign that there are inadequacies in a program. When annually a specific program loses a resident, and at least some of those residents go on to match, enter, and complete other residencies, I think that is a clear sign of problems within the residency program itself. Those problems may include problems with remediation policies, education, or a systemic problem with the culture of the program or personalities of individuals in power (what I would actually call malignancy). It may be rare, but there are quite a few programs out there that lose a resident almost annually.

The real problem I see is with lack of transparency and relatively short memory of individuals within the program or the data for the programs. As an applicant, if I'm applying to a 3 or 4 year residency, I can't look at a roster and say, "oh look, they lose a resident every year" because if they kick someone out of the 2nd or 3rd year class every year, I'll only see 1 or 2 empty spots in the program. How would I even know this was due to someone getting kicked out, as opposed to leaving for other reasons. The program will never tell me about the person that gets kicked out, and I'd have to rely on the senior residents who are either the chiefs, who will likely not tell me about such things since a big part of their job is recruitment, or are probably the least involved in recruitment compared to earlier classes (who have not lost a resident yet).

Theoretically, retention and completion rates are part of ACGME review, but a its not like this information is widely posted or publicized in any easy to access locations. I've rotated at places as a student and resident with these problems. Sometimes the issue is a resident that would not be successful anywhere, but lets not pretend like malignancy in residencies doesn't exist.

 

[collegestud2013]

After months of perusing this forum, working with resident friends who are dealing with malignant programs it seems to me that the ACGME provides zero or limited guidance, support and accountability in this process.

It seems to me that professionals can invest 10+ years of hardwork and tremoudous sacrifice, unimaginable funds and go into insurmountable debt only to have your whole career hinge and potentially ruined by a PD with a god complex and alternative personal and professional motives. Who oversees the programs? Truly?
I’ve seen tons of ACGME documentation rules, requirements, articles and studies on burnout rates and abuse of resident programs- but when there are actual issues and residents are left hanging high and dry with no alternatives, where is the ACGME? How are they holding the programs accountable ? They seem to provide guidelines but no support. Residents are terrified to be blacklisted. Why do they exist? What role do they in fact play? How are they letting these malignant programs not only jeopardize the careers of dedicated professionals but ultimately are the ones churning out doctors whose training could potentially not meet basic health care standards.
Is healthcare in our country broken from inception?

The ACGME conducts an annual resident survey for each resident and fellowship program in the country. The survey is anonymous, and at least around 60-70% of the residents are required to fill it out. Most of the questions pertain to common and specialty-specific ACGME rules and program requirements (eg duty hour violations...). Program results are compared to and ranked as a percentile with other programs in the same specialty. In theory, if the a program scores very low in one area, this can initiate a review of the program and site visit from the ACGME for possible penalties or probation as this suggests non-compliance with an ACGME rule (though how often they actually do this is unclear). Most program directors usually openly share the their program's annual ACGME survey results with their residents. Unfortunately, these survey results are not made public so it's difficult to use this as a criteria when ranking residency programs (however, on ACGME's website you can see which programs have had warnings or probations from the ACGME).

In addition, anyone can anonymously file a complaint (ACGME > Residents and Fellows > Report an Issue > Office of Complaints) to the ACGME about a specific program if they think the issue isn't being addressed internally. However, the complaint has to allege a specific violation of an ACGME program requirement, so it's only helpful for pointing out program-wide issues and will not help with resolving issues about a program with a specific resident. Not sure how effective this is, and anyone has done this before and what ACGME has actually done a result of a formal complaint, and if they were able to institute changes in a program? Or has it lead to a program being put on probation which also hurts the resident?

The definition of "malignant" is very different depending on who you ask, but for the ACGME it means violating a common or specialty-specific program requirement.

 

[Mass Effect]

Those problems may include problems with remediation policies, education, or a systemic problem with the culture of the program or personalities of individuals in power (what I would actually call malignancy).

I'd add to that list personalities of the residents. If a program repeatedly ranks individuals with toxic personalities, the program will reflect that.

Sometimes the issue is a resident that would not be successful anywhere, but lets not pretend like malignancy in residencies doesn't exist.

I don't think anyone is pretending malignancy in residencies doesn't exist. Of course it does. It's just not very common is all.