Aug 25, 2012
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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.
 
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Raryn

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As is frequently pointed out in discussions of similar issues, there has to be more to the story. If we take the OP's post at face value, (s)he had stellar performance and the PD maliciously, out of the blue, started a persecution campaign founded on lies. To get the OP out. For no reason whatsoever. Except for maybe because the OP gave some honest (but not inappropriate) feedback about the program.

While it is possible that there might be a program director in this country (with a sample of ~6000 PDs total) that would do something like that, I think it's far more likely there really was some kind of situation that triggered this.

Either way, the advice given above isn't bad, as it is a good way to protect yourself if you find a situation where you're in trouble with your program. The OP treated it correctly and got what was likely the best of all possible outcomes (credit for the year), but the underlying story is suspect.
 
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shopsteward

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....If we take the OP's post at face value, (s)he had stellar performance and the PD maliciously, out of the blue, started a persecution campaign founded on lies. To get the OP out. For no reason whatsoever. Except for maybe because the OP gave some honest (but not inappropriate) feedback about the program.

While it is possible that there might be a program director in this country (with a sample of ~6000 PDs total) that would do something like that, I think it's far more likely there really was some kind of situation that triggered this.

...the underlying story is suspect.
The OP made two "mistakes": disclosing an earlier diagnosis of a learning disorder and giving honest feedback on the program which could be (and apparently was) traced back to the OP. Discrimination against people who are known to have mental health issues/learning disorders is rampant in society in general and even among medical professionals. And it is rare to find any manager who likes getting critical feedback from people they regard as subordinates.

Also, a fairly high proportion of doctors have mental health/emotional/addiction/stress/anxiety issues. It is perfectly possible that there is a PD who is having personal difficulties who was tipped over into irrationality when feeling challenged by someone they have come to regard as of inferior status.

Sadly, I find OP's story all too convincing and the advice given sound.
 
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Aug 25, 2012
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I appreciate the comments. I don't have any more answers for you, Raryn, on the trigger. My removal had nothing to do with my performance or conduct. But what you said reminds me of another point that I wanted to raise.

How do you explain what happened to other programs?

Some of my resident colleagues and supervisors from third-world countries told me that they thought it was “so New York” and naïve to think that Corporate Compliance would rule against its own, and that the internal appeals processes at my institution would be anything but the most stacked of all possible decks. But it was incredible to me, and I can see how it might be to other people. The biggest problem I faced after being pushed out was how to explain what had happened to other psychiatry programs.

Stigma, as conceived by Link and Phelan (2001), Corrigan, Watson, and Ottati (2003), provides a majority group with system-justification for discriminatory behavior against a minority, but it can occur automatically in all of us. When confronted by accounts of social injustice, we try to make sense of it. If Bob, who's a member of a stigmatized group, is fired in spite of excellent performance, we reason that it couldn't have happened for no reason; it must be that since he's a member of that group, he didn't deserve the job. Mental health care workers are often trained to screen for objective data that could suggest the presence of mental health conditions, like being out of work, or getting kicked out of a program. And we often suspect that these conditions might have caused what happened. So how do you convince another program that you are not a walking personality disorder?

After I got kicked out, I met with a former psychiatry residency program director, and I decided that I’d tell him everything about what happened in order to get his take. In the hour that followed, it slowly occurred to me how uncomfortable he seemed in hearing it. As I thought about it afterwards, why would a program director want to hear about the incredible behavior of another director?

After the meeting, I decided the best approach for interviews was to say, “I’m happy to answer as many questions as you like about my former program (and the more you ask, the better for me), but I’d like to let you take the lead in asking.” The more information about the former program that you provide up front, the more defensive you'll seem.

I want to emphasize that this might not work for cases that aren’t as clear cut as my own. I had all-satisfactory performance evaluations, great scores, and great letters of recommendation from every psych rotation supervisor I’d had since the summer I joined, and plenty of others from medicine and neurology. When you looked at my cover letter, it was dominated by a list of 11 references, with names and titles, whose recommendations I attached. I think I could afford to let the stats doing the talking for me because these cover letters were rittled with numbers like 223, 230, 99th, 95th, names of publications, alma maters, etc. In applying my experience to your own case, it's hard to say when you can do what I did. If I were a program director, I'd assume just from all-satisfactory evaluations alone, that you probably weren't a problem resident. But I'm not a program director.

The tone of my cover letters was overwhelmingly upbeat. And they were true. I had really enjoyed my interactions with all my fellow residents, supervisors, and the patients. I had had a really good time. And I loved psychiatry.

I did not take the advice that was recommended to me by a few people, mostly by those who were unfamiliar with my situation. Some folks say that you need to do a self-psychodynamic formulation on what you did that led to your removal. But it would not have been relevant to my case, and, to me, it seems like a dangerous strategy.

I want to stop here to address some of issues you raised in your comments, Raryn, and please know that this doesn’t refer to you. If you ever go through something like I experienced, don’t ever let them tell you that you deserved it. There is nothing narcissistic (or “uppity”) about disclosing a mental health condition, about expecting to be treated like a human being. And it isn't your fault.

I want to give an example here that doesn't apply to me, but I think it may add some clarity. Let's say that you are an African-American who has just been hired. Soon after, the employer finds that you've been dressing a little too sharp for someone like you, and your style and gestures start to activate feelings of rage in the employer. One day, they explode in a barrage of racial epithets, and you're fired. One could say that since your employer hired you knowing that you were black, isn't it unlikely that race played a role in your removal?

We’re told that it always “takes two.” But this has really limited usefulness. Never stop reminding yourself that this behavior is wrong, it’s illegal, and it is totally inappropriate in medicine.

Please don’t hesitate to contact me through this site for any questions at all, or if I can be of any help.
 
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LOL. thanks for post--i had interview at Albany Medical Center--i did not like that program. PD just doodles for the whole time and the guy asks you questions. can you give skype for tips?
 

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The committee and or director sound like they are life long academics completely absorbed in psychiatry, on top of being very cynical and child like in their thought process.
 
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There are only two types of feedback to give: good, and blank. Never disclose problems to a survey that your program has access to.
 
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Just curious for Psychiatry, how many hours do you guys generally clock in during in patient months? I am going to be going to one thats like 60+ hours.
 

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this is good advice, but i'm wondering how do you figure out that a program is malignant BEFORE you join? Are there any telling signs?
And what exactly does malignancy entail? Trying to get the resident fired? giving the resident more workload than other residents? yelling at the resident?

Sorry its just that i hear the word malignant alot and dont quite exactly know what it means
 
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you just wait for programs to submit match lists . . . then call residents to ask if they fire people
 
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