Co-resident got fired, need advice

[A_hominid]

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A PGY-1 was fired at the end of PGY1 (contract nonrenewal). The program was able to hire someone else to join as a PGY-2 and everything was all good and dandy. Now in that same class, one of the PGY2 will not be advanced to PGY3. Actually, said person was never advanced to PGY2 officially in the first place because of deficiencies. Not sure if they're gonna try to keep this person and help them improve, or let them go. Program will probably not try to hire someone to fill that spot. Which leaves the PGY2 class short 1 person for the rest of this year and all of next year.

Will be meeting with PD to get more details and make requests. I need some advice.

But first, background info: my FM program has 6 resident a year, unopposed. Hospital relies heavily on residents. Residents run the ICU and run the hospital at night. There are 0 attendings in house overnight (1 ED attending but they can't legally help out on the floor since the hospital contracts out the ED docs and that's what the contract says). The overnight residents handle all the admissions, floor calls, run codes, and sometimes intubate if the attending can't get here fast enough. As the senior resident, you get to supervise all of this. There are only 2 residents overnight, a PGY-1 and either a PGY-2 or PGY-3. Point being there are lots of responsibilities - and understandable why someone would get held back - and equally hard to try to fill the spot.

Questions:
-has anyone heard of a someone being hired on as a PGY-3 in FM or IM? As a PGY3 you're expected to lead the team and navigate the system, how does this work out?
-what happens when your class is man-down? Can you expect the program to pay extra to cover all the extra call shifts and NF and inpt rotations you have to do? How much extra?
-If not, can you expect program to have attendings cover these duties?
-what else I should request at the meeting with PD?
-If PD scews us and expects all of us to work extra w/o pay for 1.5 yrs, what recourse do I have? Should I threaten to xfer to a different program? Is that even a realistic possibility?

 

[HomeSkool]

-has anyone heard of a someone being hired on as a PGY-3 in FM or IM?

I'm pretty sure you have to do at least two years with a program to graduate from it. (Perhaps one of my more knowledgeable colleagues can correct me if I'm wrong about that.) I've never heard of someone being hired as a senior.

-what happens when your class is man-down?

The rest of you pull more call shifts.

Can you expect the program to pay extra to cover all the extra call shifts and NF and inpt rotations you have to do?

Don't count on it. They'll say your hours are capped at 80 either way, so it shouldn't change your maximum on-duty time.

-If not, can you expect program to have attendings cover these duties?

LOL

-what else I should request at the meeting with PD?

I wouldn't request much if I were you. Just as much transparency as s/he is willing to provide.

-If PD scews us and expects all of us to work extra w/o pay for 1.5 yrs, what recourse do I have?

You're salaried. It's not "screwing" you to require that you work more to get the job done as long as ACGME rules aren't violated. Welcome to the real world.

Should I threaten to xfer to a different program?

Are you nuts? That's a hollow threat that will just land you in hot water. How could you transfer without your PD's approval and assistance?

Is that even a realistic possibility?

No.

 

[A_hominid]

When you interview and before you rank a program, you get a schedule regarding rotations and elective time and for entire residency. Having to do extra core rotations = less elective time = not what was agreed upon. To me, that's getting screwed. It's unfair for one side of unilaterally change something that was agreed upon.

 

[HomeSkool]

When you interview and before you rank a program, you get a schedule regarding rotations and elective time and for entire residency. Having to do extra core rotations = less elective time = not what was agreed upon. To me, that's getting screwed. It's unfair for one side of unilaterally change something that was agreed upon.

Does your contract specifically guarantee those things? And does it give the program latitude to change them if that's what's required for patient care?

EDIT: I'm pretty sure the answers to those questions are no and yes, in that order. I doubt you have anything actionable, and even if you did it would probably just make things worse. You're 17.5 months from the finish line. Just power through.

 

[A_hominid]

I read the contract 1.5 yr ago before I started and don't believe this was addressed. I will have to find it and go back and reread it. It's a def a good idea to reread it though. Thanks.

 

[HomeSkool]

I read the contract 1.5 yr ago before I started and don't believe this was addressed. I will have to find it and go back and reread it. It's a def a good idea to reread it though. Thanks.

No problem.

As a word of caution, be very conservative in your approach to this. You've worked hard for a long time to get where you are. Don't do anything rash that could derail you at the finish line. If worse comes to worst, just tough it out for 1.5 years knowing that the end is in sight.

 

[Smurfette]

Your program has time to evaluate the PGY3 rotations for next year and make adjustments.

I'm not FM, but we lost someone partway through my program and graduated one less resident in my class. My program adjusted the rotations for the future years, although it was tough for call coverage for a few months as the loss happened mid-year. Plus FM is generally more flexible than my field is (we had no electives) as far as switching things around.

How would your program adjust things if someone went on medical leave or maternity leave when assigned to the rotations your colleague had left to do? They may do some of those things in the short term for this year.

 

[rokshana]

A PGY-1 was fired at the end of PGY1 (contract nonrenewal). The program was able to hire someone else to join as a PGY-2 and everything was all good and dandy. Now in that same class, one of the PGY2 will not be advanced to PGY3. Actually, said person was never advanced to PGY2 officially in the first place because of deficiencies. Not sure if they're gonna try to keep this person and help them improve, or let them go. Program will probably not try to hire someone to fill that spot. Which leaves the PGY2 class short 1 person for the rest of this year and all of next year.

Will be meeting with PD to get more details and make requests. I need some advice.

But first, background info: my FM program has 6 resident a year, unopposed. Hospital relies heavily on residents. Residents run the ICU and run the hospital at night. There are 0 attendings in house overnight (1 ED attending but they can't legally help out on the floor since the hospital contracts out the ED docs and that's what the contract says). The overnight residents handle all the admissions, floor calls, run codes, and sometimes intubate if the attending can't get here fast enough. As the senior resident, you get to supervise all of this. There are only 2 residents overnight, a PGY-1 and either a PGY-2 or PGY-3. Point being there are lots of responsibilities - and understandable why someone would get held back - and equally hard to try to fill the spot.

Questions:
-has anyone heard of a someone being hired on as a PGY-3 in FM or IM? As a PGY3 you're expected to lead the team and navigate the system, how does this work out?
-what happens when your class is man-down? Can you expect the program to pay extra to cover all the extra call shifts and NF and inpt rotations you have to do? How much extra?
-If not, can you expect program to have attendings cover these duties?
-what else I should request at the meeting with PD?
-If PD scews us and expects all of us to work extra w/o pay for 1.5 yrs, what recourse do I have? Should I threaten to xfer to a different program? Is that even a realistic possibility?

are you having a individual meeting with the PD about this, or is this a meeting between the residents and the PD? If this is a one on one meeting then why? Are you the chief? Be careful on how you approach this...there can be blowback and unless you are willing to sacrifice your own career for this, you need to be careful.

IM requires 2 years at a program so PGY3 transfers cannot be done, but don't know if that is the case for FM.

We were down a resident in my class as well when a fellow intern did not have her contract renewed. There wasn't a noticeable difference, but we were a bigger class than you (15/year = 5 prelims) and PGY2/3 were essentially treated the same, so the residents managing the upper level responsibilities were managed by twice the number (29-30). We did have in house moonlighting that covered some shifts over the weekend that normally are covered by a senior resident, but so long as the program isn't violating any ACGME requirements, they don't have to do anything different...remember your contract is renewed on a yearly basis, so they can make changes for the requirements...what you were told as a 4th year med student during your interviews doesn't remain the same...sometimes its for the better, but sometime its not (think about the changes that had to be made after the interns were not able to do overnights, ie could only work 16 hours). If you are not violating any duty hours, then they are not really asking you to work extra.

Whether attendings will take on some duties, will depend on the culture of your program... my fellowship was unusual in that my year was the first year to be a 3:0, meaning that there were 3 of us as 1st years, but no 2nd years (2 yr clinical and 3rd yr research fellows all happen to graduate at the same time and the program decided to have 3 2yr clinical fellows instead of 2:1 clinical:research) and the attendings were more available since they basically took on the role of a senior fellow as well...had great attendings that were all very approachable so it may have been just second nature for them or they made a point of changing their culture (i suspect the former).

i once had a research professor who like to say that to gauge your level of indispensability is to think of yourself as a finger in a bucket of water...when you take your finger out of the bucket what happens? The bucket fills the hole that your finger once occupied...your "threatening" to transfer is a hollow one...you would have to find an open PGY2 spot, requiring you to repeat a year, and most importantly you will need the blessings of your PD for any other PD to seriously consider you... and that would be doubtful...you would at best get a neutral letter and remember, PDs know each other and talk...its 1.5 years...in the grand scheme of things its not that long so just power through.

 

[mvenus929]

I wouldn't count on much changing.

Our class was bigger (>20). We lost one resident at the end of intern year due to change in specialty. We lost another at the end of PGY-2 due to contract non-renewal. We gained a resident at the end of PGY-2 as well due to that person having taken a leave of absence from the year above us, and then we lost someone in the middle of PGY-3. And the schedule hadn't been adjusted at all after the contract non-renewal, so when we went to down 2 residents, we had to scramble to fill schedules.

Obviously, individually we had fewer adjustments than the people in your program, but we had to work more than all the other classes did and didn't get any additional compensation for it.

 

[A_hominid]

are you having a individual meeting with the PD about this, or is this a meeting between the residents and the PD? If this is a one on one meeting then why? Are you the chief? Be careful on how you approach this...there can be blowback and unless you are willing to sacrifice your own career for this, you need to be careful.

IM requires 2 years at a program so PGY3 transfers cannot be done, but don't know if that is the case for FM.

We were down a resident in my class as well when a fellow intern did not have her contract renewed. There wasn't a noticeable difference, but we were a bigger class than you (15/year = 5 prelims) and PGY2/3 were essentially treated the same, so the residents managing the upper level responsibilities were managed by twice the number (29-30). We did have in house moonlighting that covered some shifts over the weekend that normally are covered by a senior resident, but so long as the program isn't violating any ACGME requirements, they don't have to do anything different...remember your contract is renewed on a yearly basis, so they can make changes for the requirements...what you were told as a 4th year med student during your interviews doesn't remain the same...sometimes its for the better, but sometime its not (think about the changes that had to be made after the interns were not able to do overnights, ie could only work 16 hours). If you are not violating any duty hours, then they are not really asking you to work extra.

Whether attendings will take on some duties, will depend on the culture of your program... my fellowship was unusual in that my year was the first year to be a 3:0, meaning that there were 3 of us as 1st years, but no 2nd years (2 yr clinical and 3rd yr research fellows all happen to graduate at the same time and the program decided to have 3 2yr clinical fellows instead of 2:1 clinical:research) and the attendings were more available since they basically took on the role of a senior fellow as well...had great attendings that were all very approachable so it may have been just second nature for them or they made a point of changing their culture (i suspect the former).

i once had a research professor who like to say that to gauge your level of indispensability is to think of yourself as a finger in a bucket of water...when you take your finger out of the bucket what happens? The bucket fills the hole where your finger once occupied...your "threatening" to transfer is a hollow one...you would have to find an open PGY2 spot, requiring you to repeat a year, and most importantly you will need the blessings of your PD for any other PD to seriously consider you... and that would be doubtful...you would at best get a neutral letter and remember, PDs know each other and talk...its 1.5 years...in the grand scheme of things its not that long so just power through.

It will be a class meeting. We had a class meeting when we lost our PGY1 classmate and were starting the search for a replacement. I had asked for moonlighting pay and got it for call shifts, but I'm afraid that won't translate to normal rotation since that's a lot of $$. It's easy to have someone cover the role of PGY1 or just do without, and make the senior work harder. But there's no substitute for a PGY3. The attendings honestly can't navigate the EMR and don't know how to do med recs or put in discharge orders. Yes, they'll make all the other PGY3s work more to make up for the missing person, but I would argue that the role of a PGY3 in a small unopposed program is fairly indispensable. I think the program and hospital feels the same way. Because of our coverage, they don't have to hire midwives to cover C-sections, surgery PAs to assist in overnight surgeries, nocturnalists, or PAs to do admissions for specialty services. The next step is how to convert that indispensability to $$. I know docs are notoriously bad at negotiating their pay. Lots of old attendings are being paid less than new grads because they never asked for a raise.

How much did the program pay you guys for in house moonlighting?

 

[ThoracicGuy]

A PGY-1 was fired at the end of PGY1 (contract nonrenewal). The program was able to hire someone else to join as a PGY-2 and everything was all good and dandy. Now in that same class, one of the PGY2 will not be advanced to PGY3. Actually, said person was never advanced to PGY2 officially in the first place because of deficiencies. Not sure if they're gonna try to keep this person and help them improve, or let them go. Program will probably not try to hire someone to fill that spot. Which leaves the PGY2 class short 1 person for the rest of this year and all of next year.

Will be meeting with PD to get more details and make requests. I need some advice.

But first, background info: my FM program has 6 resident a year, unopposed. Hospital relies heavily on residents. Residents run the ICU and run the hospital at night. There are 0 attendings in house overnight (1 ED attending but they can't legally help out on the floor since the hospital contracts out the ED docs and that's what the contract says). The overnight residents handle all the admissions, floor calls, run codes, and sometimes intubate if the attending can't get here fast enough. As the senior resident, you get to supervise all of this. There are only 2 residents overnight, a PGY-1 and either a PGY-2 or PGY-3. Point being there are lots of responsibilities - and understandable why someone would get held back - and equally hard to try to fill the spot.

Questions:
-has anyone heard of a someone being hired on as a PGY-3 in FM or IM? As a PGY3 you're expected to lead the team and navigate the system, how does this work out?
-what happens when your class is man-down? Can you expect the program to pay extra to cover all the extra call shifts and NF and inpt rotations you have to do? How much extra?
-If not, can you expect program to have attendings cover these duties?
-what else I should request at the meeting with PD?
-If PD scews us and expects all of us to work extra w/o pay for 1.5 yrs, what recourse do I have? Should I threaten to xfer to a different program? Is that even a realistic possibility?

You need your program far more than they need you.

 

[deleted480308]

You need your program far more than they need you.

Yeah, keep your head down and get to attendings....it’s like being in cross Atlantic flight, you never win by threatening to jump

 

[rokshana]

It will be a class meeting. We had a class meeting when we lost our PGY1 classmate and were starting the search for a replacement. I had asked for moonlighting pay and got it for call shifts, but I'm afraid that won't translate to normal rotation since that's a lot of $$. It's easy to have someone cover the role of PGY1 or just do without, and make the senior work harder. But there's no substitute for a PGY3. The attendings honestly can't navigate the EMR and don't know how to do med recs or put in discharge orders. Yes, they'll make all the other PGY3s work more to make up for the missing person, but I would argue that the role of a PGY3 in a small unopposed program is fairly indispensable. I think the program and hospital feels the same way. Because of our coverage, they don't have to hire midwives to cover C-sections, surgery PAs to assist in overnight surgeries, nocturnalists, or PAs to do admissions for specialty services. The next step is how to convert that indispensability to $$. I know docs are notoriously bad at negotiating their pay. Lots of old attendings are being paid less than new grads because they never asked for a raise.

How much did the program pay you guys for in house moonlighting?

almost 10 years ago 😱 but was $30/hour...even then not that much, but you covered either the ICU or CCU as the senior. The intern did the admissions, you were there really just to help out. During the week , there was a CCU/MICU Night senior.

your're right in a way, but the attendings CAN do those things and they CAN hire midlevels...don't fall into a false sense of security that they can't do w/o the senior resident...they can.

 

[anonperson]

It will be a class meeting. We had a class meeting when we lost our PGY1 classmate and were starting the search for a replacement. I had asked for moonlighting pay and got it for call shifts, but I'm afraid that won't translate to normal rotation since that's a lot of $$. It's easy to have someone cover the role of PGY1 or just do without, and make the senior work harder. But there's no substitute for a PGY3. The attendings honestly can't navigate the EMR and don't know how to do med recs or put in discharge orders. Yes, they'll make all the other PGY3s work more to make up for the missing person, but I would argue that the role of a PGY3 in a small unopposed program is fairly indispensable. I think the program and hospital feels the same way. Because of our coverage, they don't have to hire midwives to cover C-sections, surgery PAs to assist in overnight surgeries, nocturnalists, or PAs to do admissions for specialty services. The next step is how to convert that indispensability to $$. I know docs are notoriously bad at negotiating their pay. Lots of old attendings are being paid less than new grads because they never asked for a raise.

How much did the program pay you guys for in house moonlighting?

You're overestimating how much you're worth. You can ask as a class but i wouldn't get your hopes up.

You think the hospital is magically going to throw you an extra $20K or something? They already know that if they say no you have no recourse. What are you going to do, quit?

I know residents do a lot of work but I can honestly say the hospital would function fine if the program ceased to exist. Everyone is replaceable.

 

[A_hominid]

I'm very pro free market. Thought unions were bad for education and bad for our country.

But being a resident has made me revisit that notion. If you're an employee with no rights and no recourse, it's nice to be able to band together for collective bargaining. Imagine if all the residents in a hospital joined together and agreed to collective bargaining, they would have a really strong voice, since the hospital would stop functioning without them.

In 2004, some residents got together and sued AAMC over their salary, argued that hospitals across the country were joined in a monopolgy i.e. "The Match" and artificially depressing resident's salary. Laughable? Not according to the DC district court judge, who ruled in favor of the residents. In response, the hospitals got Congress to add on a last minute rider to a budget bill that exempted hospitals from anti-trust laws. No joke.

These guys are worse than the mob. They're literally above the law.

Thought experiment - what would happen if the 5 people left in my class banded together? Whether we were formally in union or not doesn't matter as long as we stick together. We're close personally and feel similarly on lots of issues. If I'm an dingus they can fire me, but they can't fire the entire senior class, esp if they can't even find one more person to hire.

Everyone's advice here has been to lay low and to suck it up. And honestly, this is probably what I'll end up doing. But just thinking aloud here.

 

[rokshana]

I'm very pro free market. Thought unions were bad for education and bad for our country.

But being a resident has made me revisit that notion. If you're an employee with no rights and no recourse, it's nice to be able to band together for collective bargaining. Imagine if all the residents in a hospital joined together and agreed to collective bargaining, they would have a really strong voice, since the hospital would stop functioning without them.

In 2004, some residents got together and sued AAMC over their salary, argued that hospitals across the country were joined in a monopolgy i.e. "The Match" and artificially depressing resident's salary. Laughable? Not according to the DC district court judge, who ruled in favor of the residents. In response, the hospitals got Congress to add on a last minute rider to a budget bill that exempted hospitals from anti-trust laws. No joke.

These guys are worse than the mob. They're literally above the law.

Thought experiment - what would happen if the 5 people left in my class banded together? Whether we were formally in union or not doesn't matter as long as we stick together. We're close personally and feel similarly on lots of issues. If I'm an dingus they can fire me, but they can't fire the entire senior class, esp if they can't even find one more person to hire.

Everyone's advice here has been to lay low and to suck it up. And honestly, this is probably what I'll end up doing. But just thinking aloud here.

the problem is you can't not show up for work...kinda of why unionization for physicians doesn't work.

then the 5 of you would no longer be residents, the remaining residents will have to take on more work and the hospital would hire some locums to run things until they hired new residents (from the pool of the unmatched med students that are looking for that unexpected opening)...finger in the bucket of water...

its not that they can't find someone...they may choose to use that spot to take an extra intern from the match.

 

[Winged Scapula]

What makes you think the hospital would "cease to function"?

How do you think the vast majority of hospitals that aren't teaching hospitals function? The attendings might not like it, but you aren't as indispensable as you think.

Furthermore you aren't going to get everyone to walk. Someone will crumble.

Finally, I hate to pull the "real world" but this is how the real world works. When one of my employee calls in sick, the others do more work. When my business partner is on vacation, I take more call, see more consults, etc. And in residency when someone was out (for whatever reason) everyone else took more call. I'd be shocked if the contract actually specified your rotations, call etc without an out. Hospital attorneys are usually pretty detailed in such instances.

 

[deleted480308]

I'm very pro free market. Thought unions were bad for education and bad for our country.

But being a resident has made me revisit that notion. If you're an employee with no rights and no recourse, it's nice to be able to band together for collective bargaining. Imagine if all the residents in a hospital joined together and agreed to collective bargaining, they would have a really strong voice, since the hospital would stop functioning without them.

In 2004, some residents got together and sued AAMC over their salary, argued that hospitals across the country were joined in a monopolgy i.e. "The Match" and artificially depressing resident's salary. Laughable? Not according to the DC district court judge, who ruled in favor of the residents. In response, the hospitals got Congress to add on a last minute rider to a budget bill that exempted hospitals from anti-trust laws. No joke.

These guys are worse than the mob. They're literally above the law.

Thought experiment - what would happen if the 5 people left in my class banded together? Whether we were formally in union or not doesn't matter as long as we stick together. We're close personally and feel similarly on lots of issues. If I'm an dingus they can fire me, but they can't fire the entire senior class, esp if they can't even find one more person to hire.

Everyone's advice here has been to lay low and to suck it up. And honestly, this is probably what I'll end up doing. But just thinking aloud here.

you are totally dead wrong that they can't fire all of you......the hospital would still function and they might have to hire some staffing or pay the attending a little more to be in the hospital instead of home call but you can be replaced

You absolutely could band together and make some group requests but the hospital can just say no, and they can always make your life worse than you can make theirs

 

[Winged Scapula]

Whats the 'House of God" aphorism?

They can always hurt you more.

 

[nlax30]

Again, as others have smartly pointed out, I'm not sure this is the mountain you want to die on. With 18 residents total and down one, I'm sure the schedule can be adjusted so that it's not overly burdensome and the extra call gets spread around.

My first fellowship was at a small program and at the beginning of my first year we lost both 2nd year fellows for various unforeseen reasons. The 3rd year senior fellows historically didn't take weekend call and very little weekday call, but due to our small size we lost a substantial portion of the program and the seniors thankfully stepped up and did some weekends and other call. But as a first year I certainly did more clinical months and more call then I would've normally. I never ran into duty hour issues, but the attendings did help some and we had some weekends without a fellow and one or two months without a fellow on consult service due to our small size.

Your program's size is still large enough in my opinion where being a man down for the year would not place too much of a burden on everyone else where it would be worth it to push this issue and risk burning bridges there.

Your goal is to graduate.

 

[mimelim]

A PGY-1 was fired at the end of PGY1 (contract nonrenewal). The program was able to hire someone else to join as a PGY-2 and everything was all good and dandy. Now in that same class, one of the PGY2 will not be advanced to PGY3. Actually, said person was never advanced to PGY2 officially in the first place because of deficiencies. Not sure if they're gonna try to keep this person and help them improve, or let them go. Program will probably not try to hire someone to fill that spot. Which leaves the PGY2 class short 1 person for the rest of this year and all of next year.

Will be meeting with PD to get more details and make requests. I need some advice.

But first, background info: my FM program has 6 resident a year, unopposed. Hospital relies heavily on residents. Residents run the ICU and run the hospital at night. There are 0 attendings in house overnight (1 ED attending but they can't legally help out on the floor since the hospital contracts out the ED docs and that's what the contract says). The overnight residents handle all the admissions, floor calls, run codes, and sometimes intubate if the attending can't get here fast enough. As the senior resident, you get to supervise all of this. There are only 2 residents overnight, a PGY-1 and either a PGY-2 or PGY-3. Point being there are lots of responsibilities - and understandable why someone would get held back - and equally hard to try to fill the spot.

Questions:
-has anyone heard of a someone being hired on as a PGY-3 in FM or IM? As a PGY3 you're expected to lead the team and navigate the system, how does this work out?
-what happens when your class is man-down? Can you expect the program to pay extra to cover all the extra call shifts and NF and inpt rotations you have to do? How much extra?
-If not, can you expect program to have attendings cover these duties?
-what else I should request at the meeting with PD?
-If PD scews us and expects all of us to work extra w/o pay for 1.5 yrs, what recourse do I have? Should I threaten to xfer to a different program? Is that even a realistic possibility?

Nothing good will come of making a stink over this. If you are all violating ACGME hours, you are not going to get much backing from GME. Without a credible threat of walking out, you won't get support from the hospital. We get it, you think that you are super valuable to the system and while you may make your attendings' jobs easier, you are replaceable.

One person short out of 18? Try being 1-2 residents short out of 7 (cough neurosurgery) Obviously, if your contract specifically guarantees you things, you can pursue whatever you want with a lawyer, but it is hard to think of a situation where that will benefit you in the long run. The only way I would bring this up is if you are all pushing 90-100 hours/week and it is actually impossible to cover (which is incredibly unlikely in a FM program that loses 1 out of 18 residents).

 

[A_hominid]

All good points, ladies and gents. I'm continuing my thought experiment because this is a fun argument. To address the idea that unions are powerless since doctor's can't go on strike, I came across a great post on this issue on SDN:

from Residents Union:
There are plenty of other things that a unionized group of residents could do short of a strike to apply pressure. You have to be willing to accept the consequences though of your actions. However, most union actions are protected by labor laws, so in general, you can't be fired or retaliated against for doing union activities (you can however get a crummy evaluation for other reasons).

1) Informational picket; a few residents taking turns can man a picket without difficulty. Looks bad for the hospital, no impact to care.

2) Refusal to do non-doctor duties except as an emergency: Need a patient taken to radiology? Wait for the patient transport service. Radiology can't get it scheduled and its non-urgent, but pending discharge? Fine get it the next day. Need non-urgent blood drawn? wait for the next blood draw sweep. The hospital quickly bogs down with non-discharged patients, but all the patients are healthy and safe.

3) Refusal to do purely billing duties: Provide only minimal clinical documentation required. Progress notes are short, to the point and only for transmitting information. Nothing extra to help the billing. (Non-pertinent Review of Systems otherwise negative? Additional diagnoses that increase billing? who cares). Costs the hospital money, but again, patients are not harmed.

4) Refusal to do non-essential paperwork: Disability paperwork, multiple forms, etc. Pass all that up to the attending. Makes attendings annoyed, but isn't necessarily part of your scope of work as a resident.

5) Send all outside phone calls to attendings or send EVERY patient to the ER. Many services answer their night calls with a resident pager. You could kick every phone call up to an attending level. Again, makes attendings annoyed. Could impact your eval.

As you can see, none of those would impact the patients directly under your care, which is your primary job as a resident, but as a collective action would quickly overwhelm the institution. Not advocating anyone try this as a wildcat strike, but just to point out that residents are not entirely powerless at most institutions, even without a strike threat option.​

This poster goes on to explain:

Look, I'm not promoting any of those things. BUT, someone asked about the teeth of a union without strike capabilities. I would point out that the residents' jobs are related to learning and patient care. The attending (me now) is responsible for billing and carries the ultimate responsibility in getting the patients' care (if a resident screws up, it is still on me).

In no way shape or form should ANY resident think that doing any of those things I outlined (especially #2 and #5) outside of a institution-wide announced labor action won't get them fired or held back in quick order.

For some perspective, when my father was a resident, virtually a whole class of residents got fired for daring to ask for a raise. It was pyramidal back then, so it was a little easier to get rid of people. When I was a resident I was part of resident union negotiating team and during a negotiation breakdown where management walked away from the table, we considered each of the above actions. We did informationally pamphlet one day and we had buttons that virtually every resident wore, telling patients to ask us about what residents were doing to improve their care. We, as a union, had already ruled out striking under any circumstances, so that was never an option. The others (particularly #3 and #4), were however in our back pocket and the administration knew it, and came back to the table with new proposals quickly after seeing the seriousness of intent on our side of the table.

Yes, it is awkward to negotiate across the table from your program director, attendings, and hospital admins then go right back to work the next morning, but the good ones recognize that you are just doing your job. It's not personal, it's just what you've been elected to do by your peers. Similarly, they, as chair or director, often have to tell people no, even when they have good ideas, because that's their job too. As long as you keep the negotiating table professional and avoid personal attacks, it usually works out ok. In fact, during the worst of our negotiation, we had many attendings stand in support of the residents against the administration, as we contemplated what the next steps should be.

The bulk of what resident unions really want is better for patients too. Besides improved pay, holiday pay, etc., we routinely negotiated for things like more ancillary support for patient care activities (patient transport, blood draw sweep frequency, etc.). Even little details, like if you got called in for a consult from home, the ability to park in the ER parking lot for a short period of time to improve response times for consults. These benefited all clinicians, residents and attendings alike. Negotiation does not have to be adversarial, but when I see programs that the residents are suffering and complain that they are powerless, it occurs to me that having official aggressive representation is not always a bad thing.

Being a professional is putting forth a code of ethics and living by them, even when they hurt you. In our case as physicians, it means putting the patient over your own needs. It does not have to mean putting the administration's needs before your own needs as well. It is our job to make the system work as well as possible, that means actively pointing out to administration how to make things better. If you think a union is only about getting more money for residents, then, you probably don't need a union at your institution.​

I do think it's okay to negotiate and ask for things as long as everyone is professional about it. No personal attacks. I had asked for moonlighting pay when one of our classmates left and actually got it for the 2 months it took to to train up the new PGY2. My next step is to study the PGY3 rotations and figure out what changes administration might want and what changes I would want.

 

[deleted480308]

Makes attendings annoyed, but isn't necessarily part of your scope of work as a resident.

your scope is pretty much whatever they tell you it is

 

[NotAProgDirector]

You absolutely can join a union as a resident. CIR is the usual player, their web site is here: Committee of Interns and Residents/SEIU Healthcare | CIR Network Membership Signup and their wikipedia site is here: Committee of Interns & Residents - Wikipedia

You can even form your own informal union, if you'd like. Just your classmates, for example.

All of those items above are potentially illegal, or will get you fired. Items 2-5 are work slowdowns, or otherwise could be interpreted as a professionalism problem, or poor clinical care. Laws vary by state, but I would be very worried about all of those.

Item #1 is probably OK. It doesn't involve any work slowdown issue. You'd need to do it on your "time off". If you're picketing / informing the public while I'm paying your salary, that's a problem. Also, it may violate hospital policies, although even so it may be protected by law.

As mentioned, your best option at this point is to go into this meeting with a positive attitude, and try to help solve the situation. If you arrive angry and bitter, and threaten to form a union, you may find that things get much worse.

One extra issue here -- in a normal employment situation, when a worker leaves, their salary money is still available and can sometimes be redistributed to people who have to pick up the slack. In GME, the money for residents is based upon the resident themselves -- when they leave, the money leaves also. This isn't an excuse, but you need to understand that the money needs to come from somewhere.

 

[operaman]

I was/am a union member from my past artistic career prior to medicine. Our union both helpful and somewhat powerless as we artists/employees were many and jobs were few and we absolutely needed the companies more than they needed us. That said, most companies had a good relationship with the union and it did end up providing an avenue through which workers could discuss important issues with management collectively without risking their own livelihood in the process. On occasions when it went bad, it got really bad for everyone involved. I suppose that's one aspect of unionization that gets overlooked: exercising your power comes with a lot of unintended consequences and pain even beyond the things you anticipated.

I don't really think a true union would be of much benefit to residents overall and end up being just another things that's taken from your paycheck but doesn't really do you much good. Honestly, I think one of the most powerful things residents have is the fact they are a large driver of the reputation for any given program. Programs with a poor culture get talked about and this directly impacts future recruiting and overall reputation. Whenever I see programs in our rather competitive field that fail to match a resident, I have to admit I'm not terribly surprised as they tend to be placed that I've heard stories and rumors of less than ideal resident experiences. There's clearly a lag time on this, but overall I would expect most programs want their trainees to succeed and go on to make them proud and reflect well on where they came from.

Personally, I would love to see the ACGME champion a system that publishes data on all he programs in the country. They already collect survey data each year; I wish they would make this available to prospective applicants so they can have some decent insider data to compare programs. Even better: compile the survey data into a few major subcategories (ie. QOL, quality of training, Institutional culture, etc) and then RANK all the programs by specialty according to those metrics by specialty. Maybe even have an overall score and rank by that. We all know how institutions care very deeply about rankings of any kind (ie. remember those Doximity rankings that everyone poo-pah'd the first year and then every program was mounting campaigns the next year to ensure all their eligible alumni voted?). I believe that a number of programs who found themselves at the bottom of certain rankings would probably be surprised and mortified to be there and voluntarily look for ways to improve (some obviously wouldn't give a flip at all). This would provide a means of accountability for programs and hospitals where residents are concerned with no damage to patient care and the safety of anonymity for trainees to answer honestly.

As for the OP, it sucks but I think you're going to have to just deal with more call and spreading the extra work among the class. That's a given. I think hiring a midlevel is probably a non-started because the lag time on doing that may be such that the person starts after you graduate. I've seen us hire one new NP during my training so far and it was at least a year from when I first heard about it until someone actually started the job, and who knows how long it was in the works before that. It's been at least 1.5 years that we've been talking about hiring another and it hasn't happened yet (a major driver of this for us: rankings).

I would sit down with your class and try to figure out a list of requests that are actually reasonable and would make this painful situation a little less so. I think inquiring about adding midlevel coverage is worth mentioning but know that it probably won't happen unless you guys do a rigorous cost analysis and show the administration how hiring a billing midlevel provider would actually be financially viable and beneficial (this was part of how the 2nd NP happened for us). The education vs service dilemma is as old as residency itself and there's no easy answer; just assume that your program is on your side and look for things you can do to nudge the needle more toward the educational side of the equation.

 

[WingedOx]

Your program has time to evaluate the PGY3 rotations for next year and make adjustments.

Interesting. I've never heard of this, so it's possibly just an IM thing? PG4 transfers can and do happen in psych, though programs also have a bunch of open spots due to child fast tracking.

 

[Raryn]

Interesting. I've never heard of this, so it's possibly just an IM thing? PG4 transfers can and do happen in psych, though programs also have a bunch of open spots due to child fast tracking.

It's an issue with contuinity clinic requirements in IM if I remember correctly. You have to have X clinics in the same setting, which ends up meaning that your last 2 years must be in the same place.

The psych fourth year is unique amongst specialties as being almost entirely electives at most programs, so it's probably different.

 

[operaman]

I’ll add a couple more things here.

For those talking unionization, something real you could actually do right now to better your training environment would be to get involved with your hospital house staff council. I think most places have some form of this where residents meet periodically with the bigwigs and raise issues affecting the house staff. Most residents don’t want to do it at all so getting a seat would be a cinch and you would immediately have a voice with the biggest decision makers in your hospital. Your PD would appreciate having a passionate and engaged resident taking on such a role, and it is also something that goes on the ol CV and can lead to other leadership roles. It doesn’t have the sex appeal of big strikes and unionization, but it could actually happen, won’t destroy your career, and could actually make life better for residents at your institution.

In my own experience, when you sit down with stakeholders and start talking about issues you’ll find there are layers of complexity you didn’t even imagine. I was most surprised to realize just how tight money actually was despite the perception that it was plentiful. You may also find that admin is far more open and supportive of house staff than you realize.

 

[A_hominid]

Met with PD as a class to discuss concerns. PD agreed to pay for moonlighting shifts which is awesome. We didn't talk specifics in terms of money but based on previous moonlighting pay, I'd expect $300-$600 for a 12 hr shift. Said resident who is being held back may or may not be renewed next year. If renewed, the resident can help out with rotations since a lot of the "senior resident" role can be fulfilled by either a PGY-2 or PGY-3.

PD is actually looking to bring on a PGY-3, but as mentioned here, that gets tricky. A resident has to spend 2 yrs at one program to graduate. The exception to that is if a program is shutting down, then that requirement is waived and residents are free to xfer. And in that case the xferring resident will bring the funding with him/her. Which of course makes our program happy.

As far as we know, there are no FM programs that is shutting down this year. If anyone knows differently please gimme a holler! Though if PD is willing to pay moonlighting shifts, hell maybe I'll just take the extra $$...

 

[hallowmann]

$600 for a 12-hr shift? $50/hr. I guess its nice to be in your own system, but I'd imagine you'd make quite a bit more elsewhere (you would around here at least). Just make sure your malpractice and everything covers you, as in these are considered residency activities. It would suck to be considered on a separate contract for the "moonlighting".

If they treat it the same as other moonlighting opportunities that you already participate in or just like a bonus, then its probably fine, but just make sure that's the case.

 

[gutonc]

I actually think that $50/hr for picking up a shift the PD could easily just make you do anyway is pretty reasonable. Sure...it’s probably less than could be obtained with external moonlighting, but I think it’s a very reasonable compromise.

 

[hallowmann]

I actually think that $50/hr for picking up a shift the PD could easily just make you do anyway is pretty reasonable. Sure...it’s probably less than could be obtained with external moonlighting, but I think it’s a very reasonable compromise.

Oh, absolutely. Its obviously far better than having the extra work without compensations, which the PD could easily expect.