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I was a PGY1 psych resident from 2013-2014. I achieved all-satisfactory rotation and peer evaluations in all ACGME areas and scored in the 99th and 95th percentiles (1st in my class) of the PRITE, but was eventually non-renewed and denied all training credit.
I was told that it would not be possible to kick me out, but it was, and I was informed of the final decision much too late to be able to secure another spot. Through the help of a lawyer and the strong support of my supervisors, I was able to receive credit and gain a PGY2 contract at another program in the upcoming year.
There are many things about this experience worth sharing that should be useful for anyone entering residency, particularly in psychiatry.
(1) Never disclose any information related to mental health to a program director, especially in psychiatry.
Part of the genesis of my interest in psych came from growing up as a child with a Specific Learning Disorder and ADHD, Predominantly Inattentive Presentation. I eventually outgrew accommodations and was able to score 223 on Step 1, and 230 on CK, which I was proud of. I disclosed these diagnoses because I was proud of overcoming them, had a strong academic record, and thought that such personal experience would be an asset in the profession and be seen as such.
I had no idea that my program director and her associate had a history of repeatedly breaking the law by requesting her resident employees to submit to an administrative psychiatric evaluation (to NY State's Committee for Physician Health) in the absence of any direct threat posed by the residents to patients. And where no such threat existed, she would create it.
Just as it happened with the others, my director later requested unfettered access to all of my past mental health records, including prior evaluations, diagnoses, and treaters. I had my own provider, but she required that I see a psychiatrist of her choosing who could speak to her about anything she wished, in plain violation of federal and state disability laws and regulations. The DIO submitted the matter to Corporate Compliance, but the Senior Vice President for Corporate Compliance and the Vice Dean for Academic Administration actually encouraged her requests, while agreeing that I posed no direct threat to patient care. See http://www.eeoc.gov/facts/health_care_workers.html for an easy-to-read explanation of the relevant laws.
My directors had made a lot of disparaging remarks about my diagnoses, which I'll leave out. They are very important in any discrimination case. It's speculation on my part, but they seemed to view people who disclose mental health diagnoses as personality-disordered malingerers who disclose as an excuse in order to self-handicap and avoid taking responsibility for shortcomings.
(2) What to do when you are required to write your ticket out of the program.
In the absence of sufficient evidence to fire me, my directors required that I produce it myself. They required that I provide them with a written document in which I state that I believed I was deficient in 9 ACGME milestone areas of required clinical competence below the level expected for my level of training. (She described this as a "simple learning exercise" intended to help me succeed.)
I attempted to protect myself by working on the document with GME. The DIO agreed that I wouldn't have to put that in writing and could state simply that I believed there was always room for improvement in the areas she cited, and I created written plans for such improvement. My directors repeatedly criticized the documents I created for not containing the statement they wanted and cited them as evidence that I could not respond to their feedback. But by obtaining GME's approval of these drafts, I was able to show that I was, in fact, self-reflective and committed to self-improvement. I was never provided with any type of remedial plan from the program.
Of course, none of these actions on my part worked with the internal review processes at my institution. The Vice Dean, cited as a major ally by program administration, had ironically written at length about the importance of other people taking responsibility for medical mistakes, and this individual factor probably weighed in the outcome. But no legal or any other body outside the institution would ever see these requests as legitimate.
(3) Keep a record of everything.
For cases of wrongful termination (or non-renewal) involving residents, the resident must establish that the program's rationale for termination was capricious and arbitrary, or in bad faith. This legal standard makes it very difficult for a resident to pursue a case of wrongful termination, as the vast majority of rationales provided by employers for terminating their employees are deemed reasonable by the courts. In my case, I was told that I could well have been reinstated in the program if I'd pursued this. And I think part of this has to do with keeping good records.
For an employer's decision to be considered capricious, arbitrary, or made in bad faith, you have to know something about what information the employer had when she made her decision. For a program director to fire a resident when the report on his performance is that he has all-satisfactory evaluations, well within the range of his class, at the top on the PRITE, seems capricious and arbitrary. The issue is, what information did the employer have when the decision was made to dismiss the resident?
My director's strategy was to solicit information off the record from various individuals who might have come in contact with me. She solicited verbal reports of my performance which were "misinterpreted," but I was often able to obtain an account of the information she was provided from her sources. On one occasion, I was tipped off about one of her surveys that she had put out through email in order to document problems, and I was able to view the exchanges, which portrayed me positively.
My directors initially wrote to me that the reason I was being non-renewed related to care provided by me and my supervisor on one evening on call for a patient with HTN, though my supervisor had congratulated me for doing a "good job" taking care of the patient. Weeks later, my director called a meeting just as this supervisor went on vacation, at which time she urged me to "admit" to certain actions which, had I performed, would have meant that I posed a direct threat to patients. Fortunately, there existed online a point-by-point account of all that happened that evening, as documented by the nurses involved, which substantiated everything I said. I typed it out and presented it to my director in a public meeting. Outside the institution, my director would not have been able to successfully argue that my non-renewal, if based in this event, was being made in good faith, given the information that she was presented.
I discovered a similar instance at the very end of my time in the program, when I looked through my complete resident file with GME, which contained the minutes from my appeal of non-renewal. Unfortunately, the appeals process at my institution was structured so that you are interviewed separately from your program directors. As such, you don't know what you have been accused of, and have no chance to defend yourself from whatever is said about you at the time of the proceedings. The minutes contained summaries of my directors' claims. My director had created an elaborate scenario that actually involved one of my recommendation letters in IM, though he was never contacted. The program director for IM, however, had been contacted by my director, who requested that he provide specific written documentation about my performance. The program director for IM told me about it, assured me that I was not implicated in his documentation, confirmed the positive feedback that I had received on the rotation, and reassured me about what he had communicated in writing to my director. His memo was kept out of my files, but there was good evidence to suggest that my directors had conspired to create false accounts of my performance.
There were other instances like this. My director notified me at the end of the academic year that she would like to give me training credit for the year, but that, unfortunately, I could not receive it because she had placed me on "direct supervision." Luckily, a faculty member was nice enough to provide me with an email from my director that described my responsibilities consistent with indirect supervision, the same status as that of the other residents.This eventually made it difficult for my director to deny me residency training credit.
It goes without saying, obtain copies of your evaluations on rotations and from peers. There were over a dozen other additional extra evaluations that I had passed and kept note of. Keep track of what is in your file (both the department and GME versions). View your file, bring a laptop, and type what you are not allowed to make a copy of. Keep copies of all the work you do. And print out your emails.
(4) Be careful of programs where the Chair and Program Director are the same.
One of the biggest problems at my former program was that the same person was Program Director, Chair, Inpatient Medical Director, and Outpatient Medical Director. The residency program has a Residency Education Committee, but the chair/director can do whatever she wants with the committee's advice, or just wait for the right quorum when an important vote comes up. The leadership team becomes insulated from feedback, and much more defensive on hearing it.
(5) Don't be idealistic about your program or its institution.
Never give feedback that can be viewed in a negative light on any institutional or internal review. My trouble with my own former program started when I was asked to provide feedback. I obliged, and truly thought I was being constructive and helpful. Explosions resulted. In one meeting, my associate program director brought in a printed out copy of what I thought was anonymous program feedback I had provided from the online New Innovations evaluation system, furiously claiming that what I'd written was evidence that I could not tolerate feedback. It was the beginning of abrupt episodes of rage, disparaging remarks about my diagnoses, and bizarre accusations, which I never could have anticipated.
Maybe you're in a program right now where you feel overworked, wish you were at some place more prestigious, and you're looking to transfer. Why? If you're not training at a malignant program, why risk it? If recent news or online postings are any indication, all types of programs, the Ivy League, university-based, and community-based, can be like this.
(6) Consider programs that have a residents' union, and seek early legal advice.
By the time I finally contacted a labor lawyer, everyone had been urging me to seek legal counsel. Since this was a very specialized area of labor law, I contacted the Committee of Interns and Residents in New York, NY, the largest union of its kind in the US. Someone there referred me to two lawyers known to represent residents at medical centers outside the committee: Thomas Kennedy (212) 358-1500, and Herbert Eisenberg (212) 966-8900. The later I found most helpful. Eisenberg is very experienced in resident issues, and quite passionate about discrimination.
Eisenberg was also expensive, so he referred me to another firm, and my case was taken up by Lisa Joslin. The matter was settled out of court, and my training credit was essentially used as ransom until I agreed not to take legal action against the directors.
Do not content yourself with the idea that doctors are moral enough to police themselves. Seek legal counsel early, and do not believe in the old psych folklore that if you seek legal advice, you are a personality disorder.
Whatever the reasons your director wants you out, don't take it personally. Maybe you look like someone from her past, who she hates. Maybe you happened to start training at a program with serious problems. Defend yourself and get out intact.
(7) Always do the right thing.
Work hard. Come in early, stay late, and don't report the hours, which is a lot easier when you really love the work. Make things easier on your attending and for your colleagues. Always do what is right for the patients. Take them seriously, and respect them.
If you aren't a problem resident, your supervisors will be able to observe your sincerity by the end of your rotations. I could not have survived with my career intact had it not been for their support, And I will always be grateful to them.
I was told that it would not be possible to kick me out, but it was, and I was informed of the final decision much too late to be able to secure another spot. Through the help of a lawyer and the strong support of my supervisors, I was able to receive credit and gain a PGY2 contract at another program in the upcoming year.
There are many things about this experience worth sharing that should be useful for anyone entering residency, particularly in psychiatry.
(1) Never disclose any information related to mental health to a program director, especially in psychiatry.
Part of the genesis of my interest in psych came from growing up as a child with a Specific Learning Disorder and ADHD, Predominantly Inattentive Presentation. I eventually outgrew accommodations and was able to score 223 on Step 1, and 230 on CK, which I was proud of. I disclosed these diagnoses because I was proud of overcoming them, had a strong academic record, and thought that such personal experience would be an asset in the profession and be seen as such.
I had no idea that my program director and her associate had a history of repeatedly breaking the law by requesting her resident employees to submit to an administrative psychiatric evaluation (to NY State's Committee for Physician Health) in the absence of any direct threat posed by the residents to patients. And where no such threat existed, she would create it.
Just as it happened with the others, my director later requested unfettered access to all of my past mental health records, including prior evaluations, diagnoses, and treaters. I had my own provider, but she required that I see a psychiatrist of her choosing who could speak to her about anything she wished, in plain violation of federal and state disability laws and regulations. The DIO submitted the matter to Corporate Compliance, but the Senior Vice President for Corporate Compliance and the Vice Dean for Academic Administration actually encouraged her requests, while agreeing that I posed no direct threat to patient care. See http://www.eeoc.gov/facts/health_care_workers.html for an easy-to-read explanation of the relevant laws.
My directors had made a lot of disparaging remarks about my diagnoses, which I'll leave out. They are very important in any discrimination case. It's speculation on my part, but they seemed to view people who disclose mental health diagnoses as personality-disordered malingerers who disclose as an excuse in order to self-handicap and avoid taking responsibility for shortcomings.
(2) What to do when you are required to write your ticket out of the program.
In the absence of sufficient evidence to fire me, my directors required that I produce it myself. They required that I provide them with a written document in which I state that I believed I was deficient in 9 ACGME milestone areas of required clinical competence below the level expected for my level of training. (She described this as a "simple learning exercise" intended to help me succeed.)
I attempted to protect myself by working on the document with GME. The DIO agreed that I wouldn't have to put that in writing and could state simply that I believed there was always room for improvement in the areas she cited, and I created written plans for such improvement. My directors repeatedly criticized the documents I created for not containing the statement they wanted and cited them as evidence that I could not respond to their feedback. But by obtaining GME's approval of these drafts, I was able to show that I was, in fact, self-reflective and committed to self-improvement. I was never provided with any type of remedial plan from the program.
Of course, none of these actions on my part worked with the internal review processes at my institution. The Vice Dean, cited as a major ally by program administration, had ironically written at length about the importance of other people taking responsibility for medical mistakes, and this individual factor probably weighed in the outcome. But no legal or any other body outside the institution would ever see these requests as legitimate.
(3) Keep a record of everything.
For cases of wrongful termination (or non-renewal) involving residents, the resident must establish that the program's rationale for termination was capricious and arbitrary, or in bad faith. This legal standard makes it very difficult for a resident to pursue a case of wrongful termination, as the vast majority of rationales provided by employers for terminating their employees are deemed reasonable by the courts. In my case, I was told that I could well have been reinstated in the program if I'd pursued this. And I think part of this has to do with keeping good records.
For an employer's decision to be considered capricious, arbitrary, or made in bad faith, you have to know something about what information the employer had when she made her decision. For a program director to fire a resident when the report on his performance is that he has all-satisfactory evaluations, well within the range of his class, at the top on the PRITE, seems capricious and arbitrary. The issue is, what information did the employer have when the decision was made to dismiss the resident?
My director's strategy was to solicit information off the record from various individuals who might have come in contact with me. She solicited verbal reports of my performance which were "misinterpreted," but I was often able to obtain an account of the information she was provided from her sources. On one occasion, I was tipped off about one of her surveys that she had put out through email in order to document problems, and I was able to view the exchanges, which portrayed me positively.
My directors initially wrote to me that the reason I was being non-renewed related to care provided by me and my supervisor on one evening on call for a patient with HTN, though my supervisor had congratulated me for doing a "good job" taking care of the patient. Weeks later, my director called a meeting just as this supervisor went on vacation, at which time she urged me to "admit" to certain actions which, had I performed, would have meant that I posed a direct threat to patients. Fortunately, there existed online a point-by-point account of all that happened that evening, as documented by the nurses involved, which substantiated everything I said. I typed it out and presented it to my director in a public meeting. Outside the institution, my director would not have been able to successfully argue that my non-renewal, if based in this event, was being made in good faith, given the information that she was presented.
I discovered a similar instance at the very end of my time in the program, when I looked through my complete resident file with GME, which contained the minutes from my appeal of non-renewal. Unfortunately, the appeals process at my institution was structured so that you are interviewed separately from your program directors. As such, you don't know what you have been accused of, and have no chance to defend yourself from whatever is said about you at the time of the proceedings. The minutes contained summaries of my directors' claims. My director had created an elaborate scenario that actually involved one of my recommendation letters in IM, though he was never contacted. The program director for IM, however, had been contacted by my director, who requested that he provide specific written documentation about my performance. The program director for IM told me about it, assured me that I was not implicated in his documentation, confirmed the positive feedback that I had received on the rotation, and reassured me about what he had communicated in writing to my director. His memo was kept out of my files, but there was good evidence to suggest that my directors had conspired to create false accounts of my performance.
There were other instances like this. My director notified me at the end of the academic year that she would like to give me training credit for the year, but that, unfortunately, I could not receive it because she had placed me on "direct supervision." Luckily, a faculty member was nice enough to provide me with an email from my director that described my responsibilities consistent with indirect supervision, the same status as that of the other residents.This eventually made it difficult for my director to deny me residency training credit.
It goes without saying, obtain copies of your evaluations on rotations and from peers. There were over a dozen other additional extra evaluations that I had passed and kept note of. Keep track of what is in your file (both the department and GME versions). View your file, bring a laptop, and type what you are not allowed to make a copy of. Keep copies of all the work you do. And print out your emails.
(4) Be careful of programs where the Chair and Program Director are the same.
One of the biggest problems at my former program was that the same person was Program Director, Chair, Inpatient Medical Director, and Outpatient Medical Director. The residency program has a Residency Education Committee, but the chair/director can do whatever she wants with the committee's advice, or just wait for the right quorum when an important vote comes up. The leadership team becomes insulated from feedback, and much more defensive on hearing it.
(5) Don't be idealistic about your program or its institution.
Never give feedback that can be viewed in a negative light on any institutional or internal review. My trouble with my own former program started when I was asked to provide feedback. I obliged, and truly thought I was being constructive and helpful. Explosions resulted. In one meeting, my associate program director brought in a printed out copy of what I thought was anonymous program feedback I had provided from the online New Innovations evaluation system, furiously claiming that what I'd written was evidence that I could not tolerate feedback. It was the beginning of abrupt episodes of rage, disparaging remarks about my diagnoses, and bizarre accusations, which I never could have anticipated.
Maybe you're in a program right now where you feel overworked, wish you were at some place more prestigious, and you're looking to transfer. Why? If you're not training at a malignant program, why risk it? If recent news or online postings are any indication, all types of programs, the Ivy League, university-based, and community-based, can be like this.
(6) Consider programs that have a residents' union, and seek early legal advice.
By the time I finally contacted a labor lawyer, everyone had been urging me to seek legal counsel. Since this was a very specialized area of labor law, I contacted the Committee of Interns and Residents in New York, NY, the largest union of its kind in the US. Someone there referred me to two lawyers known to represent residents at medical centers outside the committee: Thomas Kennedy (212) 358-1500, and Herbert Eisenberg (212) 966-8900. The later I found most helpful. Eisenberg is very experienced in resident issues, and quite passionate about discrimination.
Eisenberg was also expensive, so he referred me to another firm, and my case was taken up by Lisa Joslin. The matter was settled out of court, and my training credit was essentially used as ransom until I agreed not to take legal action against the directors.
Do not content yourself with the idea that doctors are moral enough to police themselves. Seek legal counsel early, and do not believe in the old psych folklore that if you seek legal advice, you are a personality disorder.
Whatever the reasons your director wants you out, don't take it personally. Maybe you look like someone from her past, who she hates. Maybe you happened to start training at a program with serious problems. Defend yourself and get out intact.
(7) Always do the right thing.
Work hard. Come in early, stay late, and don't report the hours, which is a lot easier when you really love the work. Make things easier on your attending and for your colleagues. Always do what is right for the patients. Take them seriously, and respect them.
If you aren't a problem resident, your supervisors will be able to observe your sincerity by the end of your rotations. I could not have survived with my career intact had it not been for their support, And I will always be grateful to them.
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