Cheating on CMEs: or, How to get Terminated

[235750]

Hello everyone

I want to warn everyone of recent policing efforts targeting residents

I work at a large academic hospital. Recently some residents from a somewhat nearby community program came to our school to get CME materials from their stipend. Two days later they came back and returned the goods and got a full refund. They then pocketed the money, having chosen our institution because we are geographically and politically isolated from their site.

The book store, perhaps a little peeved that they were denied successful sales, contacted the site and told on the residents. Apparently they have a system in place now to check for such schemes.

Several people were dismissed. These were good doctors, people whom I knew and cared for. One was weeks away from finishing his program.

I am not a physician, but I work with interns and residents on a daily basis. Let's be honest: a large number of residents sell their CME materials, but usually they're smart about it and sell it online like on Ebay. I think it's a silly and very risky thing to do, but I understand the economic situation they're in

I want people to know to be careful if you ever sell your CME materials. It's no secret that residents can be treated like scum, but the ease at which the site dismissed the residents, some with years of good relations, was...well, shocking.

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[Samoa]

While I understand the ethical issue with purchasing CME materials and returning them after obtaining credit, I don't understand what the problem would be with re-selling them used.

Perhaps I'm missing something here. Aren't most CME programs free due to corporate sponsorship, anyway? What kind of materials are you talking about?

 

[SoCuteMD]

While I understand the ethical issue with purchasing CME materials and returning them after obtaining credit, I don't understand what the problem would be with re-selling them used.

Perhaps I'm missing something here. Aren't most CME programs free due to corporate sponsorship, anyway? What kind of materials are you talking about?

Sounds to me like it's the CME money programs allot for residents. It's generally somewhere between $400-800/yr, "use it or lose it" money. Can be used for textbooks, conferences, etc. Thankfully, my program allows us to use it for some regularly incurred expenses, so finding a way to use it isn't a problem.

 

[235750]

Sounds to me like it's the CME money programs allot for residents. It's generally somewhere between $400-800/yr, "use it or lose it" money.

Exactly, and a lot of places are required to use it.

While I understand the ethical issue with purchasing CME materials and returning them after obtaining credit, I don't understand what the problem would be with re-selling them used.

I'm not sure why you're confused...perhaps I was not giving enough details. What I described was not the re-selling of used books.

They bought $500 worth of textbooks. They then returned them in 2 days. They could not have read the books in that short amount of time. They also did not return the $500 back to the program.

The residents that I see selling boks on eBay tend to be selling them as new books online..they don't read them at all. They are poor residents so they do what they can for money

Perhaps I'm missing something here. Aren't most CME programs free due to corporate sponsorship, anyway?

Sure, loads of CMEs are free. But when a program gives you money specifically for your medical education, and you then you pocket that cash, they ain't going to be happy. Usually that money is used to fly to a conference, etc, but you can get away with purchasing books

The reason why I made this thread is because I thought it was a fairly minor infraction...maybe deserving of a fine, probation, something along those lines. Especially since abuse is so rampant, all the residents I work with have done it themselves at one time or another. I didn't think it warranted dismissal which I why I want to warn people. Plus, apparently book stores communicate to other sites so be aware people!

 

[michaelrack]

I'm not sure why you're confused...perhaps I was not giving enough details. !

People are confused because you are misusing the term "CME". CME is what practicing (attending/private) physicians do to maintain their licenses- each state requires a certain # of CME credits per year.

What the residents did in your anecdote is buy and return educational materials, not CME.

 

[Taurus]

Sorry to hear about their situation. Do these terminated residents have any hope of finishing residency somewhere?

 

[peppy]

I feel bad for that resident who was a week away from finishing residency. It seems very sad for someone's entire career to be destroyed over one bad choice
(which is not to take away from the fact that it was a horrible choice - I'm sure that resident really regrets losing so much over $500).

 

[edmadison]

I guess I'll go against the grain here. What these residents did was a crime, plain and simple. Let me simplify:

1) Program provides funds for residents for educational purposes.
2) Resident purchases educational materials.
3) Resident provides receipt to program showing purchase of educational materials and asking for reimbursement
4) Resident almost immediately returns materials pocketing the refund.

Depending on how you look at it, this is either embezzlement or fraud.

Do you have any doubt that the residents knew what they were doing was wrong?

Ed

 

[DarthNeurology]

Hello everyone

I want to warn everyone of recent policing efforts targeting residents

I work at a large academic hospital. Recently some residents from a somewhat nearby community program came to our school to get CME materials from their stipend. Two days later they came back and returned the goods and got a full refund. They then pocketed the money, having chosen our institution because we are geographically and politically isolated from their site.

The book store, perhaps a little peeved that they were denied successful sales, contacted the site and told on the residents. Apparently they have a system in place now to check for such schemes.

Several people were dismissed. These were good doctors, people whom I knew and cared for. One was weeks away from finishing his program.

What they did was wrong, and they paid a high price for it no doubt. Although I wouldn't consider myself super strict, I think that using educational funds for something else is wrong and basically stealing from the residency program. That they used a geographically isolated place shows that what they did was wrong.

But it doesn't involved patient care and I don't know if it is legally wrong?? I think the program fired them because they were basically disrespecting the residency program, not that their clinical care was lacking. I really don't know how strict the rules are governing the educational funds at a program are, i.e. you must use them for educational materials. I could see a misguided resident viewing it as a bonus that could be used for educational materials or not, but I don't think this is the case.

 

[benjee]

what they did was wrong, but they also deserve a second chance by giving them a warning or some sort, and make it clear to all house staffs in writing. Even residents made mistakes and usually given warning, put on probation..etc. I believe they deserve a second chance.

 

[bluealiendoctor]

I think people are overlooking the main problem here. It doesn't matter whether what they did is deemed criminal, unethical or both or whether it has anything to do with patient care. It shows the character of the individual and his/her potential to do said act. They most certainly know what they were doing was wrong, yet chose to follow through. So now begins the slippery slope. What else would they be willing to do for a quick buck?

 

[bluealiendoctor]

These were reisdents who worked for an institution and probably made ridiculously low wages compared to their level of education.

You mean like every other resident in the country?

I never said I agree with the punishment, but I do feel what they did was very poor judgement.

 

[lowbudget]

Taking pre-tax CME reimbursement money paid for by the program, returning the item, and taking the money in full amount without paying taxes on it is tax evasion. The residents definitely put themselves at risk for going to jail and the organization of pretty stiff fines.

I'm not a lawyer, but it reminds me of the NBA referee tax evasion story, where the NBA paid referees to fly First Class, but the referees instead bought Coach tickets, and kept the difference in cash. (http://www.usdoj.gov/opa/pr/1999/June/254tax.htm)

I'm surprised at the immediate termination though. Returning the money or forcing them to report the income taxes on the individual & organizational level would seem to be the reasonable remedy, but I can see how even that could be perceived as only a slap on the wrist. Chances are the residents didn't know any better. I guess the question really is how much do you tolerate ignorance of the law? I'm surprised that the residents, on their side, never asked any questions like will I get in trouble for this. For me, the idea of going to jail outweighs the cash or job termination.

All that being said, the program has full right to terminate these residents, for-cause or without-cause. Residents did something really stupid, and even more stupid for not asking questions for what would intuitively feel wrong.

Sounds like a bad case of See One, Do One, Teach One.

 

[Mayhem]

This is fraud and it's not just a mistake. They chose the out of the way bookstore because they thought they wouldn't get caught. That tells me they knew what they were doing was wrong. I totally agree with firing them. Besides, what could possess me to steal 500 bucks when I'm a week away from Attending money? Apart from being a criminal, the dude is just silly.

 

[JMK2005]

These residents knew what they did was wrong. They took a calculated risk. From the details that has come out so far, termination I think was an over-reaction. Unless there were other ethical concerns, they shouldn't be terminated.

What happens to a resident caught with drug abuse? The medical board usually gives them rehab, but doesn't take away their license right away. That too me is way worse.

 

[Mayhem]

It depends on how you frame it. Drug abuse is seen as an addiction, a disease. This is a choice to defraud their residency programme.

In all honesty a resident about to graduate should know better, which is probably why they cracked down so hard. We can all debate whether they were treated too roughly but like you said they took a risk and their programme called them on it. If they hadn't tried to cheat the system none of this would have happened. It's a tragedy but no injustice occurred here.

 

[DarthNeurology]

It shows the character of the individual and his/her potential to do said act. They most certainly know what they were doing was wrong, yet chose to follow through. So now begins the slippery slope. What else would they be willing to do for a quick buck?

Sadly, there are a few surgeons who supposedly do unnecessary operations and plenty of physicians who have/did take expensive vacations etc, from pharmaceutical companies, and some doctors who take on too many patients to turn a profit. The question is whether these residents would become such doctors, and I have to say compared with what a lot of physicians do, this seems pretty mild, but still is wrong.

Considering that it was a group of doctors, some of them must have been just following along i.e. peer pressure, although that is no excuse, they should have been I think put on probation or something. . .

 

[DarthNeurology]

It depends on how you frame it. Drug abuse is seen as an addiction, a disease. This is a choice to defraud their residency programme.

In all honesty a resident about to graduate should know better, which is probably why they cracked down so hard. We can all debate whether they were treated too roughly but like you said they took a risk and their programme called them on it. If they hadn't tried to cheat the system none of this would have happened. It's a tragedy but no injustice occurred here.

Drug abuse is worse I think as it puts patients in harm's way, i.e. a physician who has a drug or alcohol problem MUST know that their behavior could impact patient care. It is pathetic that some physicians with drug and alcohol abuse for years who have harmed patients can keep on practicing.

These residents may or may not have made a very poor judgment call, but they knew that they owned the books and that it wouldn't affect patient care, maybe they were ignorant of the law, but the fact that they went to another bookstore is proof enough they knew it was wrong.

There could be injustice here as the punishment outweights the crime potentially, i.e. that they will never be able to practice medicine. I think this is because the residency program felt that they were taken advantage of, while drug and alcohol abusing physicians are OK to practice with "treatment" even though they have put the lives of patient's at risk. Surely both are wrong, but one is a magnitude greater here.

 

[Taurus]

I agree that what they did was wrong, but the question is the punishment commensurate with the crime? Do they deserve to have their medical careers terminated permanently over something like this?

For those who answer yes it is, then when you get your ass dragged into court for malpractice because you missed something that you should not have, you won't get any sympathy from me. You deserve whatever punitive damages that the jury hands down. And everyone knows how fair those are in this country.

That's what's wrong with this country. So politically correct and CYA.

 

[Mayhem]

I agree that what they did was wrong, but the question is the punishment commensurate with the crime? Do they deserve to have their medical careers terminated permanently over something like this?

For those who answer yes it is, then when you get your ass dragged into court for malpractice because you missed something that you should not have, you won't get any sympathy from me. You deserve whatever punitive damages that the jury hands down. And everyone knows how fair those are in this country.

That's what's wrong with this country. So politically correct and CYA.

Missing something is a mistake. This was on purpose. Two different animals.

I don't disagree that the punishment was harsh. I'm just not particularly upset by it. I actually don't care what happens either way, it doesn't affect me beyond the fact that now I won't do something like this in case my programme decides to destroy my life.

 

[anon-y-mouse]

I realize that it's definitely sketchy, and there could be income tax ramifications, and that it's stupid to return it directly to that store... but how is this so different from using the money for books, then deciding you didn't need those books and selling them?? Residency programs give money earmarked for books, but doesn't the obligation end once the books are bought?? I would understand if the books remained the property of the residency program, but once they're bought, the residents OWN them, I would think they should be able to do whatever they want with them. These people are adults, bought the books, and they decided that they didn't need the books at all. It might not be ethical to buy, then return [or buy, then sell somewhere else], especially if you intended to sell the books in advance, but how is this behavior illegal? Residents own the books, residents can do what they want with them.

Hypothetically if I were to receive evaluation copies of books before, and I didn't feel they were relevant to me, and they were in perfect condition, what prevents me from selling them on amazon or something? They're "mine" now, right? Or if I entered a residency program that gave everyone a laptop unconditionally (which now belongs to resident, not hospital, and not used expressly for patient care), and I decided "Oh, I already have an amazing laptop, if this donated laptop is now mine, I should sell it"... Or if my grandmother gave me a sweater which I hated, and I sold that...

I know all these 'benefit' type situations veer in the grey, but I'm having a lot of trouble with the part AFTER the transaction has taken place. Shouldn't I be able to even burn the books in a bonfire if I wanted to, and not risk retaliation??? Would there have been a difference had there been a different initial intent? "Oh, I've been meaning to read Harrison's, let me buy that from my budget" --> get home, realize that the book is way too much for me to digest, decide to sell it, and invest in Pocket Medicine??

 

[Kubed]

I think people are overlooking the main problem here. It doesn't matter whether what they did is deemed criminal, unethical or both or whether it has anything to do with patient care. It shows the character of the individual and his/her potential to do said act. They most certainly know what they were doing was wrong, yet chose to follow through. So now begins the slippery slope. What else would they be willing to do for a quick buck?

… speaking of the slippery slope fallacy

 

[Taurus]

I think that there is something inherently unfair in the current process of disciplining residents. Too often, they are at the mercy of the program to decide not only their near future but whether they able to practice medicine at all. Why is it that other professionals who act unprofessionally don't face the possibility their careers terminating for such infractions? For example,

Nora B. Tuliao, New York, NY

Profession: Dentist; Lic. No. 042482; Cal. No. 24018

Regents Action Date: October 21, 2008
Action: Application for consent order granted; Penalty agreed upon: 1 year stayed suspension, 1 year probation, $500 fine.

Summary: Licensee did not contest the charge of issuing a prescription for Prozac 20 mg. and Celexa 20 mg. to a patient, although the prescription was unrelated to any dental condition.​

This person willfully practiced psychiatry when they are licensed as a dentist. The board fined them and put them on probation. The action no doubt is also on their permanent professional record. If you read the other cases, many professionals in many different fields had similarly outcomes.

Why can't we have a similar system that seems to be more fair to me? Why shouldn't medical students or residents who act unprofessionally go before a state board instead of the whims of the residency program? There are too many conflicts of interests if your fate is to be decided by your program. These programs are not impartial and that's the problem. There are lots of behind-scene politics. We grant these programs too much power if we allow them to be the judge and jury over the fate of your career.

 

[lowbudget]

I realize that it's definitely sketchy, and there could be income tax ramifications, and that it's stupid to return it directly to that store... but how is this so different from using the money for books, then deciding you didn't need those books and selling them??

Again, I'm not a lawyer or tax accountant; but you're right, there is very little difference.

If you sold the books on Ebay, for example, you really should declare your sales as income on your tax returns and pay taxes on it (if you want to be clean & legit).

Just google "IRS ebay sales"...
http://reviews.ebay.com/Taxes-and-Ebay-eBay-Sales-May-Be-Subject-To-Taxes_W0QQugidZ10000000000720733
http://www.wired.com/techbiz/media/news/2005/03/67035
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/02/24/MNGMPOAK5C1.DTL

In this case, basically, you're taking a pre-tax $500 of books, returning it, and putting $500 in cash in your pocket as if it was post-tax. And by not declared it on your returns, that's under-reporting. That's tax evasion (i.e. illegal & criminal).

If you take pre-tax $500 of books, sold it on Ebay for $500, then the declared $500 on your income taxes and walked away with $330, that would be legit IMO.

I think in reality the actual dollar amount is too small for IRS to chase. But they could. And that's the point.

That being said, I think it's an issue between the IRS & the residents to deal with.

Why the residency program get involved in it & fired the residents?

(The only thing I can think of is: Well, maybe it has to do with tax reporting of wages...)

 

[benjee]

Again, I'm not a lawyer or tax accountant; but you're right, there is very little difference.

If you sold the books on Ebay, for example, you really should declare your sales as income on your tax returns and pay taxes on it (if you want to be clean & legit).

Just google "IRS ebay sales"...
http://reviews.ebay.com/Taxes-and-Ebay-eBay-Sales-May-Be-Subject-To-Taxes_W0QQugidZ10000000000720733
http://www.wired.com/techbiz/media/news/2005/03/67035
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/02/24/MNGMPOAK5C1.DTL

In this case, basically, you're taking a pre-tax $500 of books, returning it, and putting $500 in cash in your pocket as if it was post-tax. And by not declared it on your returns, that's under-reporting. That's tax evasion (i.e. illegal & criminal).

If you take pre-tax $500 of books, sold it on Ebay for $500, then the declared $500 on your income taxes and walked away with $330, that would be legit IMO.

I think in reality the actual dollar amount is too small for IRS to chase. But they could. And that's the point.

That being said, I think it's an issue between the IRS & the residents to deal with.

Why the residency program get involved in it & fired the residents?

(The only thing I can think of is: Well, maybe it has to do with tax reporting of wages...)

I thought what a resident get is called "stipend" not salary ( the paycheck every month or biweekly ) ?? In the past, there was accountant who advertised he can help to get tax back from IRS for residents but I didn't get time to check into it. If that's stipend, then it doesn't matter it's pretax or not since IRS can't tax it.??

 

[lowbudget]

I thought what a resident get is called "stipend" not salary ( the paycheck every month or biweekly ) ?? In the past, there was accountant who advertised he can help to get tax back from IRS for residents but I didn't get time to check into it. If that's stipend, then it doesn't matter it's pretax or not since IRS can't tax it.??

Well, I don't know if I got a stipend or a salary. I do know that I was paying taxes, the whole shebang, on what I was earning.

That being said, I'm not sure if that is starting to matter anymore anyways. There was a case a couple of weeks ago where a high federal court essentially stated that residents essentially were employees and therefore subject to taxation.

http://online.wsj.com/article/SB124484480481711085.html

(I think they were talking about FICA taxes specifically, though... funny how Mayo is now on the hook for a crapload of money. Maybe that's why this CME residency program fired those bookstore residents?... Dunno.)

You know what? I wished people would just come right out and say it. Are residents students? Or employees? Make a decision. And don't tell me, "well, it depends" because those same people who change the rules every time they're losing the game of Monopoly.

I mean, would the outcome to this CME-bookstore case been different if the kids were medical students and not residents? What if they were medical students on scholarship? What if they were medical students funded by a federal military scholarship?

 

[benjee]

if the federal court said a resident is an employee, then something is wrong here cuz residency is an educational program and is funded by medicare which provides the program a lump sum of money an part of it would pay the resident. Even in the contract, it said " stipend" .Now , i"m confused.
let's say if they were meds students and were getting scholarship, then it should be ok to refund this way cuz it's supposed to be used in whatever way those students want like rooms and board ..etc .

 

[SoCuteMD]

I thought what a resident get is called "stipend" not salary ( the paycheck every month or biweekly ) ?? In the past, there was accountant who advertised he can help to get tax back from IRS for residents but I didn't get time to check into it. If that's stipend, then it doesn't matter it's pretax or not since IRS can't tax it.??

There was an appellate court ruling on this very recently. They decided residents were employees, not students.

 

[Mac4]

Our program just give us a yearly check for "education expenses".

 

[235750]

I don't disagree that the punishment was harsh. I'm just not particularly upset by it. I actually don't care what happens either way, it doesn't affect me

That's sort of an awful attitude to take..."it's not an appropriate punishment, but I don't care so long it doesn't effect me".

The disproportionate reaction to these residents is indicative of a culture that treats residents like garbage. Mayhem, I hope that you are never treated unfairly because you are a resident, but if you are I hope you remember this event because it does effect you

You should stand up for your fellow residents. Taurus is right, the programs aren't impartial at all and there needs to be more advocacy for residents

Sorry to hear about their situation. Do these terminated residents have any hope of finishing residency somewhere?

No, unfortunately they do not. The PD has said he won't give a good reference, so I'm not sure what options they have. Last time I saw them I suggested they take a look at SDN! As terminated residents, we're not supposed to talk to them, and having seen what a minor infraction incurs, I'm not taking any chances myself

What happens to a resident caught with drug abuse? The medical board usually gives them rehab, but doesn't take away their license right away. That too me is way worse.

Exactly. At our institution we had a program where a resident was addicted to alcohol and another to painkillers. Lord knows how much time passed before someone noticed and had the gumption to confront them about it. That puts patients in danger and is a lot worse I think. And Taurus showed plently of instances where justice is not being applied even-handly to physicians versus residents

A part of what I feel is perhaps guilt as well. Let me explain: these CME-related accounts that each resident has (call it what you will) are rather flexible. Sometimes they supplement a resident's trip to a conference with all associated fees being legitimate expenses reimbursable by the program. They can also be used to pay for a lecturer. So, my first contact with this site was when they hired me to do a CME presentation. Afterwards one of the senior attendings offered me lunch at any restaurant of my choosing from this account

He explained to me the use-it-or-lose-it properties of this particular account and told me to "go nuts".

Well, with his encouragement I chose the most expensive restaurant I could find. I'd never eaten lobster before so I got the largest ones and feasted on it with silver nut crackers a la Kim Jongil.

I spent unnecessary money on food. Instead of wasting it on lobster, they (the residents) put the money in their pockets. In principal I don't see a difference...I feel like maybe I deserve to be fired just as much as they did, even though the official policy says I didn't break the rules.

The attendings really set the tone for the account. Had they themselves been responsible about it, I think things would be different. The residents looked at their attendings, saw them eating filet mignon, and thought, "this account is a joke. We can use it for whatever we want. And we're residents not attendings, so I'm going to use this money not for posh food, but to pay my bills." Not an unreasonable conclusion to come to

 

[Samoa]

I realize that it's definitely sketchy, and there could be income tax ramifications, and that it's stupid to return it directly to that store... but how is this so different from using the money for books, then deciding you didn't need those books and selling them?? Residency programs give money earmarked for books, but doesn't the obligation end once the books are bought?? I would understand if the books remained the property of the residency program, but once they're bought, the residents OWN them, I would think they should be able to do whatever they want with them. These people are adults, bought the books, and they decided that they didn't need the books at all. It might not be ethical to buy, then return [or buy, then sell somewhere else], especially if you intended to sell the books in advance, but how is this behavior illegal? Residents own the books, residents can do what they want with them.

Hypothetically if I were to receive evaluation copies of books before, and I didn't feel they were relevant to me, and they were in perfect condition, what prevents me from selling them on amazon or something? They're "mine" now, right? Or if I entered a residency program that gave everyone a laptop unconditionally (which now belongs to resident, not hospital, and not used expressly for patient care), and I decided "Oh, I already have an amazing laptop, if this donated laptop is now mine, I should sell it"... Or if my grandmother gave me a sweater which I hated, and I sold that...

I know all these 'benefit' type situations veer in the grey, but I'm having a lot of trouble with the part AFTER the transaction has taken place. Shouldn't I be able to even burn the books in a bonfire if I wanted to, and not risk retaliation??? Would there have been a difference had there been a different initial intent? "Oh, I've been meaning to read Harrison's, let me buy that from my budget" --> get home, realize that the book is way too much for me to digest, decide to sell it, and invest in Pocket Medicine??

Actually, there's a line there. Selling it on eBay as a used item would be OK, for exactly the reasons you state. You own it, it's yours to do with as you please.

But returning something "unused" is a different animal. Theoretically, when you do such a thing, the effect should be as if you never purchased it at all. In other words, the money is not yours to pocket and should be returned to the account it came from. Not to do so is fraud.

 

[Mayhem]

That's sort of an awful attitude to take..."it's not an appropriate punishment, but I don't care so long it doesn't effect me".

The disproportionate reaction to these residents is indicative of a culture that treats residents like garbage. Mayhem, I hope that you are never treated unfairly because you are a resident, but if you are I hope you remember this event because it does effect you

You should stand up for your fellow residents. Taurus is right, the programs aren't impartial at all and there needs to be more advocacy for residents

It is an awful attitude to take. But I just feel it was a really silly thing to do. They knew what they did was wrong, as evidenced by going far away to a different book store. And yes residents on a whole are treated like indentured slaves, but knowing this why would risk it? We've all heard the horror stories of residents fired for the stupidest things, why then would you go an rock the boat? I don't care if the attendings are scoring coke of a Vietnamese hooker's ass with their money. If you've ever been in med school you know the world is not level. What they can get away with, we can't.

Besides, it's not like it was an accident or a mistake or they were acting in good faith and it blew up in their faces. They took a dumb risk and it bit them in the ass. So yes, it's harsh and if they were my colleagues I'd be picketing in front of the PD's office with them but right now, sitting a world away, I can't lie, there just aren't any tears. Which I suppose makes me an ******* but....

BTW, I feel like the type of PD who would do this is probably known for being a dick already, which brings me back to my original point: Why take the chance?

Actually, there's a line there. Selling it on eBay as a used item would be OK, for exactly the reasons you state. You own it, it's yours to do with as you please.

But returning something "unused" is a different animal. Theoretically, when you do such a thing, the effect should be as if you never purchased it at all. In other words, the money is not yours to pocket and should be returned to the account it came from. Not to do so is fraud.

I totally agree. I wonder why they didn't just do this instead. If dude had waited one week then he wouldn't be a resident there anymore and he'd be free to do whatever the hell he wants with the books. He could even light them on fire in the middle of the lunch room (you know, besides the fact that it's arson and all).

 

[235750]

It is an awful attitude to take. But I just feel it was a really silly thing to do. They knew what they did was wrong, as evidenced by going far away to a different book store.

BTW, I feel like the type of PD who would do this is probably known for being a dick already, which brings me back to my original point: Why take the chance?

I appreciate your candor, Mayhem. I see what you're saying, and you are correct, it was a risk they took. But again, if you read what I wrote, the attendings regularly abuse the CME account...I feel they have to share the blame here. What I am complaining about is the disparity in applied justice to residents as opposed to the attendings. Attendings really set the tone of the program and residents are quick to follow their example, and I imagine in this environment anyone might be tempted to think it was OK to break the rules. Again, I see no difference in principal between using the account to order extravagant food versus vs. just pocketing the money. Do you Mayhem?

I totally agree. I wonder why they didn't just do this instead. If dude had waited one week then he wouldn't be a resident there anymore and he'd be free to do whatever the hell he wants with the books. He could even light them on fire in the middle of the lunch room (you know, besides the fact that it's arson and all).

The bookstore just recently reported the infractions. These incidents of returning books took place of the course of this past year, so I'm not sure when he returned the books but it was some time ago.

The point with the books was to return them back to get the most money possible. I imagine when you sell them on ebay you have to discount the price. Not that this makes it right, I'm just explaining their train of thought.

Moral of the story: just because you see your attendings regularly breaking the rules doesn't mean you can get away with it. Don't follow their example. I know over the years you'll let your guard, but try to remember: you are disposable. They will treat you like garbage.

 

[JMK2005]

iloveDrStill - Something about your story doesn't quite add up. Are there things about the story that you're not privy to?

 

[Taurus]

Here's a good example of a prestigious residency program violating rules and getting slapped on the wrist for it. Do people remember that Johns Hopkins IM program was nearly put on probation for the same reasons?

MGH cited on surgeons' overload
Trainees' hours exceed safety rule; Hospital says it has fixed problem

Junior surgeons at Massachusetts General Hospital have been working too many hours, in violation of patient safety rules, according to a national accrediting organization that is threatening to put the hospital's surgery training program on probation.

The Accreditation Council for Graduate Medical Education cited the hospital because a significant number of its surgeons in training, known as residents, were exceeding hour limits and working seven days straight. The organization believes these workloads contribute to fatigue-related mistakes, and has given the hospital until Aug. 15 to fix the problem.​

So MGH acted "unprofessionally" by blatantly violating ACGME rules. If we apply the same rigor to the program that was applied to the residents that got fired, then the program director and some of the attendings should not only be fired but lose their medical licenses. Since that doesn't happen, then we have a double standard here. On the one hand, residents who act unprofessionally are at the mercy of their residency programs who may decide to end their medical careers. On the other hand, residency programs that act unprofessionally get a slap on the wrist. Does that sound ******ed and unfair to you? It sure does to me. That's why I find it sometimes comical and hypocritical when doctors cry about getting sued. It's comeuppance for their "holier than thou" attitudes.

 

[Mayhem]

Again, I see no difference in principle between using the account to order extravagant food versus vs. just pocketing the money. Do you Mayhem?

In principle no, it's an expense account for educational purposes so the attendings are just as wrong and I think they should be fired too. In practice however, they'll probably say they were having a dinner meeting to discuss educational matters and get off with a slap on the wrist. And if there happens to be a resident at the dinner, they're bulletproof. Now of course, that's bull**** but it's an easier sell than just pocketing the money. So while the attendings are not following the spirit of the rule, technically it won't be seen as breaking the rule.

 

[AnesNavy]

My 2 cents:

I agree, the punishment does not fit the crime. What the residents did was wrong, but if you or I were in that situation, I would like to be given a second chance (wouldn't you?) and not have my career in which I've worked on for 8+ years thrown down the drain for selling books. I'm sure if they knew of the consequences, they wouldn't have done it.

More importantly, I think we as residents (and medical students) can learn from their mistake. Dont sell your free books. At least, not in this manner. I also agree that residency programs have too much power and it would be better to have a regional board of some sort where residents could be disciplined. That way, if there are biased PDs, attendings, so forth, the resident is not immediately pushed out the door unjustly. 😎

 

[edmadison]

My 2 cents:

I agree, the punishment does not fit the crime. What the residents did was wrong, but if you or I were in that situation, I would like to be given a second chance (wouldn't you?) and not have my career in which I've worked on for 8+ years thrown down the drain for selling books. I'm sure if they knew of the consequences, they wouldn't have done it.

More importantly, I think we as residents (and medical students) can learn from their mistake. Dont sell your free books. At least, not in this manner. I also agree that residency programs have too much power and it would be better to have a regional board of some sort where residents could be disciplined. That way, if there are biased PDs, attendings, so forth, the resident is not immediately pushed out the door unjustly. 😎

And here is the problem in my mind. The residents were not fired for "selling books". The were fired for deceptively claiming reimbursement for educational materials. This is fraud. It was not a mistake, it was intentional -- they went out of their way to generate a receipt and hide it from their program. How would you feel if there they took $500 out of the cashier's drawer at the cafeteria? Should a resident be fired for that?

BTW, I also agree that programs can and do treat residents unfairly, especially the FMG mills. I don't think this is even close to that.

Ed

 

[3dtp]

And here is the problem in my mind. The residents were not fired for "selling books". The were fired for deceptively claiming reimbursement for educational materials. This is fraud. It was not a mistake, it was intentional -- they went out of their way to generate a receipt and hide it from their program. How would you feel if there they took $500 out of the cashier's drawer at the cafeteria? Should a resident be fired for that?

BTW, I also agree that programs can and do treat residents unfairly, especially the FMG mills. I don't think this is even close to that.

Ed

There are a couple of jewels here. The last statement is the crown. Programs do treat residents unfairly, because they can. This is wrong.

Fraud is even more wrong. The chair of a department at the University of Michigan was fired many moons ago for cheating on his travel expense vouchers by a few thousand. He is a nationally renowned specialist in his field. Along with the Director of the UMMC. A department head making a fair amount of money by anyone's standards felt it necessary to steal a few hundreds, or perhaps thousand dollars?

This comes in the category of stupidity. To quote Lazarus Long, "Stupidity cannot be cured with money, or through education, or by legislation. Stupidity is not a sin, the victim can't help being stupid. But stupidity is the only universal capital crime; the sentence is death, there is no appeal, and execution is carried out automatically and without pity."

 

[JMK2005]

...How would you feel if there they took $500 out of the cashier's drawer at the cafeteria? Should a resident be fired for that?

No.

 

[Samoa]

No.

Why not? The cashier certainly would be fired for doing so. As would any other hospital employee, without notice and likely without recourse.

 

[mcindoe]

I want to know what happens to these residents after they've been terminated...where do they go? What do they do? What happens to their medical career? Practically speaking, what are you supposed to do if you're fired as a resident (both in the short- and long-term)? Whether the punishment fits the crime is one thing; what hasn't been discussed is the reality of what happens to residents who lose their jobs. Even if these people knowingly did something wrong and deserved to be fired, they still have med school debt that may exceed $100K, and for all practical purposes the only job skills/experience they have acquired up to this point are how to be a doctor- and these aren't skills that would be of much use in any other job. I'm not saying that people shouldn't be held accountable for their actions, but getting fired from residency seems unreasonably severe because it doesn't sound like you are given any opportunity to practice medicine ever again- you can't find a new program that will want to take you, and without residency, you won't be able to get a job...you're pretty much stranded, there's nowhere to go, and after all the time and money invested in getting this far, what are you supposed to do now? It's easy to be dismissive and just say "well they should have thought about that" or "too bad", but I think that's being too overly simplistic (and a bit self-righteous, quite frankly). So, what happens now?

 

[michaelrack]

So, what happens now?

I've known several residents who have gotten fired. A typical career course is to get a job at starbucks and then later a job at a community college teaching bio or anatomy.
If they are lucky, after a while (if they have completed internship) they can get a physician job getting paid a nurse practitioner salary- perhaps working at a prison or at a large company's in-house medical clinic (ie, an auto manufacturer).

 

[NotAProgDirector]

I've known several residents who have gotten fired. A typical career course is to get a job at starbucks and then later a job at a community college teaching bio or anatomy.
If they are lucky, after a while (if they have completed internship) they can get a physician job getting paid a nurse practitioner salary- perhaps working at a prison or at a large company's in-house medical clinic (ie, an auto manufacturer).

It's not always this bad. Residents who are fired from one program can find positions in other programs. It really depends on what happened. Honestly, I'm surprised that the residents on this thread were terminated for this event, unless this is a pattern of behavior. If not, some other program will likely be willing to take them and finish their training. It will be hard work to find one, but I'm sure there's a program out there. This is better than failing out of a program due to lack of clinical skills.

 

[Excelsius]

Again, I'm not a lawyer or tax accountant; but you're right, there is very little difference.

If you sold the books on Ebay, for example, you really should declare your sales as income on your tax returns and pay taxes on it (if you want to be clean & legit).

Just google "IRS ebay sales"...
http://reviews.ebay.com/Taxes-and-Ebay-eBay-Sales-May-Be-Subject-To-Taxes_W0QQugidZ10000000000720733
http://www.wired.com/techbiz/media/news/2005/03/67035
http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/02/24/MNGMPOAK5C1.DTL

In this case, basically, you're taking a pre-tax $500 of books, returning it, and putting $500 in cash in your pocket as if it was post-tax. And by not declared it on your returns, that's under-reporting. That's tax evasion (i.e. illegal & criminal).

If you take pre-tax $500 of books, sold it on Ebay for $500, then the declared $500 on your income taxes and walked away with $330, that would be legit IMO.

I think in reality the actual dollar amount is too small for IRS to chase. But they could. And that's the point.

That being said, I think it's an issue between the IRS & the residents to deal with.

Why the residency program get involved in it & fired the residents?

(The only thing I can think of is: Well, maybe it has to do with tax reporting of wages...)

Please. Are you someone who never deviates from the rules? Do you always drive 65 on the highway? Have you ever sold anything without declaring the profits? How about forgotten to declare any gifts you have received? Did you know that any time you buy a book online where you don't pay tax for it you have to declare it to your state so that you do pay the tax?

Must feel easy to attack the residents in this case. I agree that perhaps the residents here did not make the smartest decision (they should have asked their parents or another third party to do the long distance transaction and return ), but is their "crime" worth ruining their careers, especially when they have exorbitant amounts of debt, like over half a million, and have spent close to 10 years or more training? If I was the residents, I would hire the best lawyer I could get and sue the **** out of the program. I would also contact the local politicians/press and let them know what's going on. How do you think the public is going to feel about firing these potential doctors who in turn not only will not pay a lot of taxes to the city/state because of their high future income, but will also declare bankruptcy and cost the taxpayers several millions dollars all because of program malignancy. How lame. There are thousands of students across the US who sell their textbooks online every quarter. How many do you think report their so called income?

As for "tax evasion," this is not clearly that. This is more like "tax avoidance," and that is legal. If you buy a book and then return it, there is no tax to be paid because you are not making any profit, you are just getting a refund for a returned item. Now think about this: if you think that the residents should have paid tax on that income of $500, then it does not matter for what purpose they used the $500. The income tax would have to be paid anyway, if in fact it was income. This is up to the residency program to classify it as income or non-income. If it is income, then the 500 is going to be reported to the government and the tax automatically deducted. If it is not an income, then there is no tax issue at all.

And for you record, $500 is nothing in terms of taxes. The smart businessmen out there automatically claim a $500 charity deduction every single year even though their donation ranges more like from $0 to $50 at most. Tricks like these are the reason that millionaires pay a lower income tax than the middle class. Ironically the tax % is sometime even lower than for the citizens bordering on poverty.

 

[edmadison]

Just to straighten out the tax issue once and for all. If you buy books and sell them back for less than you paid, you've lost money -- there is no tax impact.

If you sell something someone gives you, e.g. textbooks reimbursed by your program or textbooks given to you by a drug company, then you should report that as miscellaneous income on your tax return.

No for the main issue.

I think ultimately, this comes down to a line drawing problem. This was stealing, I think most of us would agree with that. But how bad does it have to be bad enough to warrant termination. Should a resident be fired for using the photo copier to advertise his garage sale? Of course not. Should the resident be fired for stealing the program director's car? Obviously.

I certainly can't put a dollar figure on where the line is, but $500 is a significant amount of money (not just a few bucks) and the residents clearly knew what they were doing was wrong. That's enough for me.

Ed

 

[dragonfly99]

What the residents did was wrong, and was akin to stealing...perhaps not quite as bad as stealing from the hospital cafeteria cash register, but for sure the residents should have known better. I do think that firing them was draconian at best. It's potentially a career death sentence. I would certainly have done something to them...perhaps for the lower level ones, I'd take away any further/future years' educational expenses. For the graduating senior resident, I'd make him pay back the money and put a letter in his file about what was done, and basically say that I'd be keeping that x five years and that if ever asked for a reference I might feel compelled to mention what happened.

Interestingly, my resident program didn't provide any kind of educational stipend, perhaps feeling it might be better to just pay residents the extra $500 and let them spend it how they would like. That is what we were told, at least. It seems like our salary was the same as other residencies, and maybe we grumbled a little about not getting any education money, but I think that it would certainly save time and headaches for the department not to have to keep track of educational stipends for all the residents, or worry about "policing" this.

I kind of wonder if there is more to the story. Had residents at this program been warned in the past about not doing things such as this, and they did it anyway?

Finally, I think this serves as yet another warning to trainees...you do not really have power in this phase of your career so be very careful what you do because you really don't have a margin for error here.

 

[3dtp]

It goes to a lack of judgment. It goes to a lack of trustworthiness. Many times in a physician's career, a choice will have to be made: Do the right thing for the patient and risk losing a potentially lucrative procedure, or not and make the next 'Benz payment.

If someone cannot be trusted with five hundred bucks, is it reasonable to presume they can be trusted with much more? I disagree with Apd on this. Clinical skills can be remediated. How do you remediate ingrained poor judgement. I wouldn't put up with this behavior from my 9 year old, let alone an adult.

Perhaps terminating them is too much. But for sure, a disciplinary letter of reprimand, outlining the issue in detail, restitution and no further educational funds, and mandatory ethics sessions.

These are the things that the State medical boards look at very carefully in the licensure process. A review of the various state medical board licensing actions on initial applications reveals that more than one physician has been denied licenses in certain states for being dishonest on a licensing document. Seemingly insignificant little white lies, in some states are disqualifying.

And with good reason. Eventually these guys will become established in the GOBN. When they do, they might be on a credentialling board, and then they can, for personal or economic reasons alone, subject a colleague to an adverse, bad faith peer review, pretty much with impunity. Do you really want to have these guys as colleagues?

As for declaring all income, you bet. I find a dime on the street, and pick it up and put it in a parking meter, I'll declare it. But I'll also deduct the mileage to drive to the parking meter as a cost of revenue. They can, if they want put you in jail for not declaring income. The most they can do if you do declare it and deduct the costs to earn it are to disallow the deduction and charge you interest. That policy has cost the IRS significant money when I've been audited.

As for driving over 65, I do it all the time. The speed limit is 75 here. And there is no point in driving faster than the speed limit. If you exceed the limit by 10% (7.5 mph here) on a 100 mile trip you save 7 minutes, which you more than lose by having to refuel that much sooner. Really worth it?

 

[mcindoe]

Re: aProgDirector's reply...Even if you are able to get a spot in a different program, how does all of this play out when it comes to your medical license? Since it would all need to be disclosed on the application, how would that affect your ability to get licensed? When you're completely honest and disclose everything on your application, how common is it for people to be denied/revoked licenses? And if they are denied, what are they supposed to do at that point? I'm just trying to get a sense of why people would want or feel the need to lie on these applications in the first place. Any insight would be appreciated.

 

[Excelsius]

It goes to a lack of judgment. It goes to a lack of trustworthiness. Many times in a physician's career, a choice will have to be made: Do the right thing for the patient and risk losing a potentially lucrative procedure, or not and make the next 'Benz payment.

If someone cannot be trusted with five hundred bucks, is it reasonable to presume they can be trusted with much more? I disagree with Apd on this. Clinical skills can be remediated. How do you remediate ingrained poor judgement. I wouldn't put up with this behavior from my 9 year old, let alone an adult.

Perhaps terminating them is too much. But for sure, a disciplinary letter of reprimand, outlining the issue in detail, restitution and no further educational funds, and mandatory ethics sessions.

These are the things that the State medical boards look at very carefully in the licensure process. A review of the various state medical board licensing actions on initial applications reveals that more than one physician has been denied licenses in certain states for being dishonest on a licensing document. Seemingly insignificant little white lies, in some states are disqualifying.

And with good reason. Eventually these guys will become established in the GOBN. When they do, they might be on a credentialling board, and then they can, for personal or economic reasons alone, subject a colleague to an adverse, bad faith peer review, pretty much with impunity. Do you really want to have these guys as colleagues?

As for declaring all income, you bet. I find a dime on the street, and pick it up and put it in a parking meter, I'll declare it. But I'll also deduct the mileage to drive to the parking meter as a cost of revenue. They can, if they want put you in jail for not declaring income. The most they can do if you do declare it and deduct the costs to earn it are to disallow the deduction and charge you interest. That policy has cost the IRS significant money when I've been audited.

As for driving over 65, I do it all the time. The speed limit is 75 here. And there is no point in driving faster than the speed limit. If you exceed the limit by 10% (7.5 mph here) on a 100 mile trip you save 7 minutes, which you more than lose by having to refuel that much sooner. Really worth it?

I don't disagree with anything, really. Yes, they should have been reprimanded, but termination is just too harsh.

I am pretty sure you are sarcastic about declaring the dime or any other money you find. Someone who is clever enough deduct "cost of revenue" is going to use some discernment and not declare certain things at all. If you find a $100 on the street, it's yours to keep. You don't declare it. Now if you're really paranoid, you spend it as cash and never have it cycle through your bank account.

In CA the max you can go is 70, but mostly the speed is 65. In some areas it is 55. Nevertheless, just like you, most people drive here at around 75. So we have a massive law breakage going on! This may be a bit off topic, but wanted to mention a few things: what makes you lose a lot of fuel is 1. Braking, 2. Changing speeds rapidly and frequently, 3.Driving too slow, 4. Driving too fast. 5. All those other things, like tire deflation, lack of lubrication, carrying heavy junk in your car (including oversized audio). Bottom line - if you are driving on a highway at 75MPH on cruise control, you are not going to spend significantly more fuel than you would at 65 and the savings in time are not canceled out by the trip to the gas station. 7 minutes might not seem much, but if you save that much every day, then by the time you die you will have saved almost 7 months (that's 24 hours a day, every day). Comes out to almost 2 years if you only include the daylight times 😉.