Contract Non-Renewal

[atillius]

I am in a bit of a predicament. I completed my first year of residency. I was failed on 2 rotations. Despite passing the repeat rotation, my program director asked me to repeat my intern year. I complied and am in the process of repeating my intern year. I was failed on yet another rotation. They placed me in academic probation. I have gone through probation and feel as if I am going to be let go. I have not failed another rotation. I have passed all my rotations on probation. I feel like this because, when I seek feedback on my performance on rotations, it is generally positive and am given a few areas to work on. I work on those areas and show improvement. Individual faculty evaluations reflect this. However, when it comes to the overall evaluation, I get blindsided. I have a feeling that this is going to happen to me at present.

I don't know what I can do if I am let go from this residency. I would have completed 24 months of residency at the end of June. I don't know how I would go about finding another program or convincing another program to take me.

What are my options?

I have looked at other forums. I understand I can be a GP in certain states. I am a US IMG. I think the only states I could do anything in are Wyoming and Wisconsin.

I am really looking at trying to continue in residency. My program director states he will write me a positive LOR, but with the caveat that it may include reasons for contact non-renewal. I'm told this is different from getting fired, by feels the same to me.

Should I appeal my decision or resign if the committee chooses to accept my PD?

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[serimeri]

I am in a bit of a predicament. I completed my first year of residency. I was failed on 2 rotations. Despite passing the repeat rotation, my program director asked me to repeat my intern year. I complied and am in the process of repeating my intern year. I was failed on yet another rotation. They placed me in academic probation. I have gone through probation and feel as if I am going to be let go. I have not failed another rotation. I have passed all my rotations on probation. I feel like this because, when I seek feedback on my performance on rotations, it is generally positive and am given a few areas to work on. I work on those areas and show improvement. Individual faculty evaluations reflect this. However, when it comes to the overall evaluation, I get blindsided. I have a feeling that this is going to happen to me at present.

I don't know what I can do if I am let go from this residency. I would have completed 24 months of residency at the end of June. I don't know how I would go about finding another program or convincing another program to take me.

What are my options?

I have looked at other forums. I understand I can be a GP in certain states. I am a US IMG. I think the only states I could do anything in are Wyoming and Wisconsin.

I am really looking at trying to continue in residency. My program director states he will write me a positive LOR, but with the caveat that it may include reasons for contact non-renewal. I'm told this is different from getting fired, by feels the same to me.

Should I appeal my decision or resign if the committee chooses to accept my PD?

Sorry to hear about your situation. What Specialty is this?

 

[atillius]

It's a family medicine residency.

 

[22031 Alum]

Do you know you aren't getting a contract renewal- as in, have been told by your PD? Or are you just guessing? If the latter, try not to worry about it yet. You might be fine. But it should be said, failing multiple rotations usually takes something pretty egregiously bad- oversights that harm patients, gross breaches of professionalism, academic deficiencies that imply you would harm patients if left to your own devices... without fixing whatever it is, you're going to have a hard time. It will be hard to find another place willing to take a risk on you.

 

[psych72]

Do you know you aren't getting a contract renewal- as in, have been told by your PD? Or are you just guessing? If the latter, try not to worry about it yet. You might be fine. But it should be said, failing multiple rotations usually takes something pretty egregiously bad- oversights that harm patients, gross breaches of professionalism, academic deficiencies that imply you would harm patients if left to your own devices... without fixing whatever it is, you're going to have a hard time. It will be hard to find another place willing to take a risk on you.

Isn't the whole purpose of residency to learn these things? You can't expect someone to be perfect at these things but overtime you would see improvement in their abilities

 

[22031 Alum]

Isn't the whole purpose of residency to learn these things? You can't expect someone to be perfect at these things but overtime you would see improvement in their abilities

There is a huge difference between making mistakes expected of someone who's learning, and behavior that leads to actually failing a rotation. In most cases. I don't know OP's situation so who knows what the failures were for. But, in general, saying "I'm a resident, I'm learning" is no excuse for, say, lying about doing something, or for being careless. For example- early in residency I messed up postpartum orders for a patient with diabetes because I didn't know her insulin doses needed to be reduced. It could have harmed her, but it was caught and I was educated. That is a "purpose of residency" mistake. Now if I'd kept doing the same thing over and over again with subsequent patients, with no indication that I'd learned any better... that's moving toward rotation failure territory. Another example- giving a post-op patient with low urine output lasix to "fix it" is a "purpose of residency" mistake. Being asked about urine output and making up numbers when you actually don't know is lying/unprofessional behavior. Do you see that difference??

Edit- I just want to emphasize that we have no idea what OP's situation actually is. I just wanted to be clear that while making mistakes is a normal part of residency, it usually doesn't lead to people repeating rotations/years unless there is something really bad/dangerous happening.

 

[psych72]

There is a huge difference between making mistakes expected of someone who's learning, and behavior that leads to actually failing a rotation. In most cases. I don't know OP's situation so who knows what the failures were for. But, in general, saying "I'm a resident, I'm learning" is no excuse for, say, lying about doing something, or for being careless. For example- early in residency I messed up postpartum orders for a patient with diabetes because I didn't know her insulin doses needed to be reduced. It could have harmed her, but it was caught and I was educated. That is a "purpose of residency" mistake. Now if I'd kept doing the same thing over and over again with subsequent patients, with no indication that I'd learned any better... that's moving toward rotation failure territory. Another example- giving a post-op patient with low urine output lasix to "fix it" is a "purpose of residency" mistake. Being asked about urine output and making up numbers when you actually don't know is lying/unprofessional behavior. Do you see that difference??

Edit- I just want to emphasize that we have no idea what OP's situation actually is. I just wanted to be clear that while making mistakes is a normal part of residency, it usually doesn't lead to people repeating rotations/years unless there is something really bad/dangerous happening.

Thanks for the clarification. Even though I'm going into Psychiatry, I'll be sure not to make the same mistakes over and over again with patients. Learning on the job type of thing I see.

Let's say your mistake didn't get caught about the insulin, and you would have harmed the patient, would you or your attending be held liable?

 

[Winged Scapula]

Its mid May, you should have already had your contract signed for next year. What's the exact situation?

 

[gutonc]

Its mid May, you should have already had your contract signed for next year. What's the exact situation?

^This. Contracts are usually signed in March, before the Match. If you haven't already been given a contract to sign, I'd wager the die is already cast.

 

[Winged Scapula]

^This. Contracts are usually signed in March, before the Match. If you haven't already been given a contract to sign, I'd wager the die is already cast.

This is what has confused me since the beginning.

ACGME requires that residents be given written notice of contract non-renewal intent and that it be given 120 days in advance of the termination of the contract (usually June 30). The OP makes it sound like he's unaware of whether or not his contract is or isn't being renewed.

 

[as90]

This is what has confused me since the beginning.

ACGME requires that residents be given written notice of contract non-renewal intent and that it be given 120 days in advance of the termination of the contract (usually June 30). The OP makes it sound like he's unaware of whether or not his contract is or isn't being renewed.

I read in my contract that non renewal can be any time, it didn't specify 120 days...it has to do with funding or with poor performance.

Likewise, it didn't specify how much notice a resident has to give if he/she wishes to transfer or not stay for PGY2. The system is there to protect PD's from what I gather.

 

[Winged Scapula]

I read in my contract that non renewal can be any time, it didn't specify 120 days...it has to do with funding or with poor performance.

Likewise, it didn't specify how much notice a resident has to give if he/she wishes to transfer or not stay for PGY2. The system is there to protect PD's from what I gather.

I see you post a lot in the Osteopathic forums; did you match into an Osteopathic residency? If so, ACGME rules don't apply.

If you matched into an ACGME program, then either your program is in violation of the ACGME Institutional requirements or you are misinterpreting the contract. Here is the verbiage from ACGME:

Non-renewal of appointment or non-promotion: In instances where a resident’s agreement will not be renewed, or when a resident will not be promoted to the next level of training, the Sponsoring Institution must ensure that its programs provide the resident(s) with a written notice of intent no later than four months prior to the end of the resident’s current agreement. If the primary reason(s) for the non-renewal or non- promotion occurs within the four months prior to the end of the agreement, the Sponsoring Institution must ensure that its programs provide the resident(s) with as much written notice of the intent not to renew or not to promote as circumstances will reasonably allow, prior to the end of the agreement.

You are correct that non-renewal can be at any time, just no later than 4 months before the end of the year (i.e., March 1). Programs aren't required to wait until march 1 to tell you they aren't renewing you. If the action leading to non-renewal occurs between March 1 and July 1, programs are only requirement to give you as much notice as circumstances will "reasonably allow".

 

[as90]

I see you post a lot in the Osteopathic forums; did you match into an Osteopathic residency? If so, ACGME rules don't apply.

If you matched into an ACGME program, then either your program is in violation of the ACGME Institutional requirements or you are misinterpreting the contract. Here is the verbiage from ACGME:

Non-renewal of appointment or non-promotion: In instances where a resident’s agreement will not be renewed, or when a resident will not be promoted to the next level of training, the Sponsoring Institution must ensure that its programs provide the resident(s) with a written notice of intent no later than four months prior to the end of the resident’s current agreement. If the primary reason(s) for the non-renewal or non- promotion occurs within the four months prior to the end of the agreement, the Sponsoring Institution must ensure that its programs provide the resident(s) with as much written notice of the intent not to renew or not to promote as circumstances will reasonably allow, prior to the end of the agreement.

You are correct that non-renewal can be at any time, just no later than 4 months before the end of the year (i.e., March 1). Programs aren't required to wait until march 1 to tell you they aren't renewing you. If the action leading to non-renewal occurs between March 1 and July 1, programs are only requirement to give you as much notice as circumstances will "reasonably allow".

I'm in an ACGME program. Yes you are right. I misinterpreted it, the contract says dismissal so immediate termination, not non-renewal of next years contract.

 

[atillius]

Do you know you aren't getting a contract renewal- as in, have been told by your PD? Or are you just guessing? If the latter, try not to worry about it yet. You might be fine. But it should be said, failing multiple rotations usually takes something pretty egregiously bad- oversights that harm patients, gross breaches of professionalism, academic deficiencies that imply you would harm patients if left to your own devices... without fixing whatever it is, you're going to have a hard time. It will be hard to find another place willing to take a risk on you.

I know my PD is recommending that my contract not be renewed. I go in front of a committee the beginning of next month. I have an opportunity to make my case on why I should stay. At that point they will decide whether to take the PDs recommendation or to reverse his recs.

I have not done anything egregious. They do not have any particular example of harm. They continue to state that I have "critical thinking" issues that make them question my ability to supervise junior residents and thus do not recommend that I move on to a PGY-2 position. My ITE scores are okay. There has not been any issues brought against me. There has not been any instances where my plan for a patient was severely lacking. There is just concerns about my ability to supervise junior residents because of my "deficient critical thinking skills."

My PD states he will support me in trying to find another residency. He has said that he would write me a positive LOR w/ the caveat that he would include information about areas that he feels I need improvement on.

 

[atillius]

Imo this is another example of the many sdn threads where someone posts an incomplete story and therefore makes it difficult for anyone to make pertinent comments.

I am happy to give you any information that you want to know. It is not as if I am trying to hide anything. I posted a basic synoposis of what has happened to me. Please ask me any questions you have. I have really just been blindsided by this and am trying to figure out my next course of action.

 

[22031 Alum]

I hear "critical thinking issues," and all I can think is "Yikes." Knowledge deficits can be fixed with diligent work, but a consistent inability to apply knowledge properly- which is what critical thinking is- is a huge red flag. If that is anywhere in your LOR, I'm not sure anyone would call it "positive" despite what your PD says.

I can't imagine there being no specific incidents that caused this concern, but you are definitely within your rights not to share them here.

 

[gutonc]

You failed nearly 20% of your rotations. The best you can hope for at this point is to be offered the chance to repeat your intern year. You're absolutely not going to be promoted so just put that option, out of your mind.

2nd best option is being allowed to resign with a strong LOR beforehand.

 

[22031 Alum]

"Critical thinking issues." What does that even mean? Is this code for something in the PD world?

In my program, which has lost... well, let's just say that we're not shy about asking people to leave, the reasons people go are (1) dishonesty, (2) poor academic performance, and (3) interpersonal conflicts. What exactly is a "critical thinking issue"?

I interpret it as having okay book learning, but for whatever reason, lacking when it comes to applying that knowledge. It's probably what you guys lump in with poor academic performance. You ever have a resident who could do average on your ITE, but couldn't formulate a plan on a real, live patient if their lives depended on it?

Actually... you might not. In my experience these are generally people who struggled mightily with Steps, but managed to memorize enough facts and test-taking strategies to eke out barely-passing scores, without really being capable of good higher-order thinking. In all honesty those people probably don't end up in Ortho.

 

[atillius]

I hear "critical thinking issues," and all I can think is "Yikes." Knowledge deficits can be fixed with diligent work, but a consistent inability to apply knowledge properly- which is what critical thinking is- is a huge red flag. If that is anywhere in your LOR, I'm not sure anyone would call it "positive" despite what your PD says.

I can't imagine there being no specific incidents that caused this concern, but you are definitely within your rights not to share them here.

So an example given to me of my lack of "critical thinking": a patient sends me for a prenatal visit. She was having lower abdominal pain prominently at rest. it has been going on for a week or two. She's having whitish discharge. I felt the pain was likely secondary to the BV. However I wanted to be certain there was nothing more serious going on. I had ruled out things like appendicitis from my history. Because my physical exam didn't include deep palpation of the pts abdomen and when I presented, I didn't remember the specific amount of time she had stated, I showed poor critical thinking. This is seriously the example that my PD gave me.

Another example is: I was called during night float about a patient. The patient was there being treated for a DVT. The pt only had one kidney. She had poor kidney function prior to admission and only worsened since. I was called for a critical potassium level. Concerned that the increase in potassium was caused by her kidneys failing, I chose not to give any fluids. Instead I chose to give kayexalate and calcium gluconate. What I had not been told at checkout was that the patient has been having diarrhea throughout the day. I was told I showed poor critical thinking in this instance because I didn't recognize her volume status was low. She didn't have tachycardia or an abnormally low blood pressure.

There are very few concrete examples that I have been given. The majority of the things I'm told about are instances where I freeze while being pimped.

 

[atillius]

You failed nearly 20% of your rotations. The best you can hope for at this point is to be offered the chance to repeat your intern year. You're absolutely not going to be promoted so just put that option, out of your mind.

2nd best option is being allowed to resign with a strong LOR beforehand.

Sadly, I am already repeating my intern year. This repeat year, I have been failed on one rotation. This was despite 3/4 attending passing me. The one who failed me on paper, verbally telling me he was going to pass me. The one who failed me was my program director. I ended up with a failing grade there. The theme from the core faculty has been the lowest grade I receive is ultimately my final grade.

 

[atillius]

I see you post a lot in the Osteopathic forums; did you match into an Osteopathic residency? If so, ACGME rules don't apply.

If you matched into an ACGME program, then either your program is in violation of the ACGME Institutional requirements or you are misinterpreting the contract. Here is the verbiage from ACGME:

Non-renewal of appointment or non-promotion: In instances where a resident’s agreement will not be renewed, or when a resident will not be promoted to the next level of training, the Sponsoring Institution must ensure that its programs provide the resident(s) with a written notice of intent no later than four months prior to the end of the resident’s current agreement. If the primary reason(s) for the non-renewal or non- promotion occurs within the four months prior to the end of the agreement, the Sponsoring Institution must ensure that its programs provide the resident(s) with as much written notice of the intent not to renew or not to promote as circumstances will reasonably allow, prior to the end of the agreement.

You are correct that non-renewal can be at any time, just no later than 4 months before the end of the year (i.e., March 1). Programs aren't required to wait until march 1 to tell you they aren't renewing you. If the action leading to non-renewal occurs between March 1 and July 1, programs are only requirement to give you as much notice as circumstances will "reasonably allow".

I just don't know what "reasonably allow" means. This is Jimmy room it's fair that if you find out by March 1 you have the opportunity go through SOAP to find another spot. Addition you plenty of time to try and find another spot and another residency before academic year is up.

Does anyone have experience in contesting a non-renewal by this route?

 

[Shikima]

I wouldn't worry too much. I knew of a guy who was forced to repeat his Internship in IM and went on to be Chief Resident in Neurology. Buckle down and keep working at it and ask questions.

 

[gutonc]

Sadly, I am already repeating my intern year. This repeat year, I have been failed on one rotation. This was despite 3/4 attending passing me. The one who failed me on paper, verbally telling me he was going to pass me. The one who failed me was my program director. I ended up with a failing grade there. The theme from the core faculty has been the lowest grade I receive is ultimately my final grade.

So, this current year, the one rapidly coming to an end, is your 2nd shot at being an intern in this same program? Am I correct on this? Because if this is true and you failed another rotation this year, in addition to the 2 from last year, then I'm afraid it's definitely game over and time to move on. You're not going to win this one.

 

[NotAProgDirector]

So an example given to me of my lack of "critical thinking": a patient sends me for a prenatal visit. She was having lower abdominal pain prominently at rest. it has been going on for a week or two. She's having whitish discharge. I felt the pain was likely secondary to the BV. However I wanted to be certain there was nothing more serious going on. I had ruled out things like appendicitis from my history. Because my physical exam didn't include deep palpation of the pts abdomen and when I presented, I didn't remember the specific amount of time she had stated, I showed poor critical thinking. This is seriously the example that my PD gave me.

Another example is: I was called during night float about a patient. The patient was there being treated for a DVT. The pt only had one kidney. She had poor kidney function prior to admission and only worsened since. I was called for a critical potassium level. Concerned that the increase in potassium was caused by her kidneys failing, I chose not to give any fluids. Instead I chose to give kayexalate and calcium gluconate. What I had not been told at checkout was that the patient has been having diarrhea throughout the day. I was told I showed poor critical thinking in this instance because I didn't recognize her volume status was low. She didn't have tachycardia or an abnormally low blood pressure.

There are very few concrete examples that I have been given. The majority of the things I'm told about are instances where I freeze while being pimped.

The honest truth is that at this time of year, these types of problems are serious problems. In the first case, you have a young woman with abdominal pain with a white discharge here for a prenatal visit. Your diagnosis was BV, which is questionable since BV usually doesn't have abdominal pain (some dysuria is possible). So, if I were talking to you about it, I'd be worried that you're on the wrong track and that something else is causing her abdominal pain -- so I would want to know the basics about it. If you couldn't tell me how long she had the pain, and reported that you didn't adequately examine her abdomen, I would consider that a major problem.

In the second case, you're called for hyperkalemia in a patient with CRI. This is a classic medicine problem, and the key is to sort out why the K was high -- low volume status / prerenal, medication (heparin), K replacement, myonecrosis, etc. What sounds like happened is that you just gave her kayexalate and Ca. It is poor form that the team didn't sign out the diarrhea to you, but neither did you check the chart / check with the nurse / check with the patient to sort it out.

In order to promote you to the PGY-2, your program needs to be confident that you can evaluate basic patients with indirect supervision (and supervise an intern). The examples you quote make me concerned this is not the case.

I agree with the prior comment, your program is going to terminate you at the end of the year. At this point, I'd recommend simply asking.

 

[Gastrapathy]

If they try to not renew rather than terminate, they will technically be in violation of the ACGME rules. However, if you push the issue, they can just fire you. If they offer non-renewal and full credit for the year, you'd be wise to take it and move on. Maybe point out that they violated the rules and that you expect that their letter will state that you successfully completed the year and nothing more. The fact that you are going in front of a committee makes me think you are being terminated rather than nonrenewed.

Also, did you really treat a patient with acute hyperkalemia over the phone? If that's the case, you're lucky you weren't fired the next day. Your rationale on that case makes no sense at all. If you can't see that now, we have problem.

 

[geauxg8rs]

The first thing a senior resident or an attending is going to ask you is
"how'd the pt look?"

If you never saw the patient you are not going to win an argument. You are toast right there.

The other point is if you are placed in situations where there is uncertainty (and you have a history of failing a rotation) I would ask for help from a senior(after having seen the patient).

When the ship is sinking don't sink alone! Take friends with you.

 

[Winged Scapula]

The first thing a senior resident or an attending is going to ask you is
"how'd the pt look?"

If you never saw the patient you are not going to win an argument. You are toast right there.

The other point is if you are placed in situations where there is uncertainty (and you have a history of failing a rotation) I would ask for help from a senior(after having seen the patient).

When the ship is sinking don't sink alone! Take friends with you.

Yep.

I got reamed by the chief resident when I called him about an ICU patient from the call room. I learned that lesson very early on. You can never be faulted by going and seeing the patient and writing a note.

 

[caffeinemia]

There is a huge difference between making mistakes expected of someone who's learning, and behavior that leads to actually failing a rotation. In most cases. I don't know OP's situation so who knows what the failures were for. But, in general, saying "I'm a resident, I'm learning" is no excuse for, say, lying about doing something, or for being careless. For example- early in residency I messed up postpartum orders for a patient with diabetes because I didn't know her insulin doses needed to be reduced. It could have harmed her, but it was caught and I was educated. That is a "purpose of residency" mistake. Now if I'd kept doing the same thing over and over again with subsequent patients, with no indication that I'd learned any better... that's moving toward rotation failure territory. Another example- giving a post-op patient with low urine output lasix to "fix it" is a "purpose of residency" mistake. Being asked about urine output and making up numbers when you actually don't know is lying/unprofessional behavior. Do you see that difference??

Edit- I just want to emphasize that we have no idea what OP's situation actually is. I just wanted to be clear that while making mistakes is a normal part of residency, it usually doesn't lead to people repeating rotations/years unless there is something really bad/dangerous happening.

Totally get this. It's a matter of insufficient experience/knowledge versus insufficient diligence. The former can be rectified because you have the tools to learn, but the latter is an intrinsic deficiency in the willingness to care and learn.

The honest truth is that at this time of year, these types of problems are serious problems. In the first case, you have a young woman with abdominal pain with a white discharge here for a prenatal visit. Your diagnosis was BV, which is questionable since BV usually doesn't have abdominal pain (some dysuria is possible). So, if I were talking to you about it, I'd be worried that you're on the wrong track and that something else is causing her abdominal pain -- so I would want to know the basics about it. If you couldn't tell me how long she had the pain, and reported that you didn't adequately examine her abdomen, I would consider that a major problem.

In the second case, you're called for hyperkalemia in a patient with CRI. This is a classic medicine problem, and the key is to sort out why the K was high -- low volume status / prerenal, medication (heparin), K replacement, myonecrosis, etc. What sounds like happened is that you just gave her kayexalate and Ca. It is poor form that the team didn't sign out the diarrhea to you, but neither did you check the chart / check with the nurse / check with the patient to sort it out.

In order to promote you to the PGY-2, your program needs to be confident that you can evaluate basic patients with indirect supervision (and supervise an intern). The examples you quote make me concerned this is not the case.

I agree with the prior comment, your program is going to terminate you at the end of the year. At this point, I'd recommend simply asking.

I find that the medical approach versus the surgical approach is so different! My moves in sequential order would have been:
#1: abdominal exam, labs, US or CT. (granted, I am not an Gyn/OB so I don't touch the hooha.)
#2: review patient history, fluid status, meds, then exam.

 

[caffeinemia]

Yep.

I got reamed by the chief resident when I called him about an ICU patient from the call room. I learned that lesson very early on. You can never be faulted by going and seeing the patient and writing a note.

It's also way more CYA when you see the patient and write a note. I don't know about you but New Yorkers are very litigious. Also, it shuts da nurses up.

 

[atillius]

The first thing a senior resident or an attending is going to ask you is
"how'd the pt look?"

If you never saw the patient you are not going to win an argument. You are toast right there.

The other point is if you are placed in situations where there is uncertainty (and you have a history of failing a rotation) I would ask for help from a senior(after having seen the patient).

When the ship is sinking don't sink alone! Take friends with you.

I went saw the pt. Pt appeared in similar condition to when I saw her on a prior night. I consulted my senior. He agreed with my assessment. I wrote a note. My senior backed me up on this.

 

[atillius]

If they try to not renew rather than terminate, they will technically be in violation of the ACGME rules. However, if you push the issue, they can just fire you. If they offer non-renewal and full credit for the year, you'd be wise to take it and move on. Maybe point out that they violated the rules and that you expect that their letter will state that you successfully completed the year and nothing more. The fact that you are going in front of a committee makes me think you are being terminated rather than nonrenewed.

Also, did you really treat a patient with acute hyperkalemia over the phone? If that's the case, you're lucky you weren't fired the next day. Your rationale on that case makes no sense at all. If you can't see that now, we have problem.

My PD says his recommendation is contract non-renewal.

For the record, I did go assess the pt. Wrote a note. My senior saw the pt as well. He agreed that we should not do IV fluids because of the patients kidney status.

And the Abdominal pain pt ended up improving after treatment of the BV.

 

[atillius]

The honest truth is that at this time of year, these types of problems are serious problems. In the first case, you have a young woman with abdominal pain with a white discharge here for a prenatal visit. Your diagnosis was BV, which is questionable since BV usually doesn't have abdominal pain (some dysuria is possible). So, if I were talking to you about it, I'd be worried that you're on the wrong track and that something else is causing her abdominal pain -- so I would want to know the basics about it. If you couldn't tell me how long she had the pain, and reported that you didn't adequately examine her abdomen, I would consider that a major problem.

In the second case, you're called for hyperkalemia in a patient with CRI. This is a classic medicine problem, and the key is to sort out why the K was high -- low volume status / prerenal, medication (heparin), K replacement, myonecrosis, etc. What sounds like happened is that you just gave her kayexalate and Ca. It is poor form that the team didn't sign out the diarrhea to you, but neither did you check the chart / check with the nurse / check with the patient to sort it out.

In order to promote you to the PGY-2, your program needs to be confident that you can evaluate basic patients with indirect supervision (and supervise an intern). The examples you quote make me concerned this is not the case.

I agree with the prior comment, your program is going to terminate you at the end of the year. At this point, I'd recommend simply asking.

I was able to tell a rough time frame of when the pain started, how it progressed, etc. I even documented it. I just couldn't recite the exact time the pt had said. I did examine the abdomen, but did not feel deep palpation was warranted. I feel their judgements are based off of my presentations. I have been directly observed, both with and without my notice. There has not been an issue with my exam skills or history from the observations. The issue comes when presenting a patient. I know this is a weakness. I get nervous depending on the attending and bumble around a bit. I am working on it and have improved.

The issue is that I was never able to see what they were talking about. I was hypervigilant about seeking out feedback. What I needed to do to improve. The feedback I was getting was all positive and saying I was improving. This is both verbally and in writing. I would make a point to address any areas for improvement. I cannot correct something, if I do not see the problem. I want to improve.

My next step is to speak in front of a committee and state why I feel I should remain at the program. As I state my case to the committee, what do I say to them that would make them at least give pause and reconsider the PDs recommendation? Is there anything that I can say?

I plan saying that the terms of my probation were that if I did not show improvement in the given areas, I would not be renewed. However, my evaluations show that there has been improvement in all areas. Throughout the probation, I was never told by anyone that I was not improving enough. I have been complimented on my attitude and efforts on all my evaluations. To not renew my contract is wrong as there was no way to know that I was not improving enough based on the information provided to me. I just want the opportunity to continue to improve and rise to the level and beyond of what is expected of me.

 

[Gastrapathy]

You should know your institution's policies forward and backward. Look at the institutional GME rules for non renewal. They will parrot the ACGME rules that say that they should give you 4 months notice unless something happens in the last four months of your contract that requires non renewal. In this case, it was an ongoing problem and you should state that you were surprised to be non-renewed given your improved feedback and the local policy requiring 4 months notice. Don't threaten them. Just say you were surprised and disappointed and that this obviously is a career-threatening situation for you that you take incredibly seriously. Thank them for their time. Go through any evals you have and pull out all the positive comments (passing rotations, etc). State that you fully recognize that you struggled and agreed with your extension of training. They will know that you can sue them for failing to follow their own policies. They will not let the PD fire you instead of non-renewing because that is obviously retaliatory.

You still are unlikely to get through the program and should look to transfer while still in good standing if you survive.

That said, the sentence that the pt with abdominal pain improved with BV treatment puts you squarely in the "lack of insight camp." BV doesn't cause abdominal pain. So, treating BV didn't make the pain better. It is just as likely that the Flying Spaghetti Monster blessed your patient. And what does "I didn't feel deep palpation was warranted" mean? There is only one type of abdominal exam for an intern.

My third grade teacher always told my mother that my behavior was improving. She was smart enough to realize that meant that I wasn't behaving.

 

[serimeri]

I was able to tell a rough time frame of when the pain started, how it progressed, etc. I even documented it. I just couldn't recite the exact time the pt had said. I did examine the abdomen, but did not feel deep palpation was warranted. I feel their judgements are based off of my presentations. I have been directly observed, both with and without my notice. There has not been an issue with my exam skills or history from the observations. The issue comes when presenting a patient. I know this is a weakness. I get nervous depending on the attending and bumble around a bit. I am working on it and have improved.

The issue is that I was never able to see what they were talking about. I was hypervigilant about seeking out feedback. What I needed to do to improve. The feedback I was getting was all positive and saying I was improving. This is both verbally and in writing. I would make a point to address any areas for improvement. I cannot correct something, if I do not see the problem. I want to improve.

My next step is to speak in front of a committee and state why I feel I should remain at the program. As I state my case to the committee, what do I say to them that would make them at least give pause and reconsider the PDs recommendation? Is there anything that I can say?

I plan saying that the terms of my probation were that if I did not show improvement in the given areas, I would not be renewed. However, my evaluations show that there has been improvement in all areas. Throughout the probation, I was never told by anyone that I was not improving enough. I have been complimented on my attitude and efforts on all my evaluations. To not renew my contract is wrong as there was no way to know that I was not improving enough based on the information provided to me. I just want the opportunity to continue to improve and rise to the level and beyond of what is expected of me.

I feel you regarding the presenting part. It seems we get so little exposure to doing it as med students, and for those of us who are shy, and not so good at eye contact, its hard to juggle all things at once, without mumbling. I wish there was a good guide (video etc.) on this area.

 

[NotAProgDirector]

OP -- Thank you for your clarifications, it makes the story sound better. It's possible that your care is fine, but that your presentation of overnight events gets so bumbled that people assume that you had no idea what you were doing. For example, you called your senior to help you assess hyperkalemia. That's something I would expect an end of year intern to manage themselves -- unless the patient needs acute HD or transfer to the ICU. So if you can't explain clearly what you did and why, I might wonder whether the senior basically made the decisions. And, as mentioned above, the BV was almost certainly not the cause of the patient's abdominal pain, which resolved on it's own.

From a practical standpoint, you have completed two PGY-1 years. No program is going to continue your training at the PGY-1 level. So the question for the promotion committee / PD is whether you're ready for a PGY-2 position. If yes, then you should be promoted to the PGY-2 level. If not your contract will not be renewed. Any argument you make needs to be that you're ready for PGY-2 responsibilities. based on the content of this thread, I am not certain you're ready for that. Failing a rotation in your repeat PGY-1 is a huge red flag -- after 12 months of experience, you should not be failing rotations.

Of note, your program has been very generous -- I extend PGY-1's who are not ready for PGY-2 by 6 months. If they are not ready for promotion to the PGY-2 by then, their training ends. Honestly, I think this is more fair to them, and gives them time to look for a new PGY position.

 

[Gastrapathy]

Tired,

The answer is that they don't have to be fair. What recourse does he have? He can beg for a decent letter and try to find another program or he can sue. Civil suits take years. Lawyers and $$ are involved. He could lose. And then what? The power balance is so skewed that they really can ignore their own policies and get away with it most of the time.
FWIW, I think the military GME programs are exceeding patient with poor performers. I've never seen anyone fired who wasn't terrible ( nonrenewal doesn't exist in the .mil).

 

[Gastrapathy]

At your place, the board is GMEC. It's composition at other places is variable depending on the number of programs.

Did you see anyone fired who you would have let operate on you?

 

[Trauma Surgeon]

Hells no. One more reason I really like my program.

The more relevant question would be, how many resident who you wouldn't let operate on you did they keep? I have seen a couple of people getting sacked, but honestly it was more of a personality (often bias) thing than anything else. If we would scrutinize every decision made by any doctor (regardless of level of training or academic degree) we would find shortcomings/wrong decision makings by all of them. I truly believe if they are liked and the patient did not suffer any major complication they would be of the hook. It is not the case if the person is not in your liking and makes a mistake that not even did jeopardized the patient safety…

For the record, as it is presented, I do believe that OP got a fair treatment.

 

[link2swim06]

My PD says his recommendation is contract non-renewal.

For the record, I did go assess the pt. Wrote a note. My senior saw the pt as well. He agreed that we should not do IV fluids because of the patients kidney status.

And the Abdominal pain pt ended up improving after treatment of the BV.

It's possible that it could cause suprapubic discomfort but unlikely actual abdominal pain.

Maybe it's my ER mindset, but you gotta r/o all the scary **** first before arriving at BV.

If you have sufficiently determined through history, exam, and testing that it is not: rupture of membranes, chorioamnionitis, septic abortion, pid, ovarian torsion, appendicitis, SBO, diverticulitis, UTI, pyelo, herpes, etc...then ok call it at BV or constipation or a round ligament pain or muscle pain or anything else pretty benign and have the patient f/u.

You will occasionally be wrong but you are doing it all wrong if you haven't at least considered those other diagnoses first.


And are kidney problems a contraindication for fluids? If so I have been doing it all wrong...

 

[Mass Effect]

I feel you regarding the presenting part. It seems we get so little exposure to doing it as med students, and for those of us who are shy, and not so good at eye contact, its hard to juggle all things at once, without mumbling. I wish there was a good guide (video etc.) on this area.

Why are you getting little exposure to presentations? What year are you? As a third year, you should/should have gotten a ton of presentation experience. Every patient you see should be presented to an intern/resident/attending. If that wasn't the case, then your seniors did you a disservice.

 

[atillius]

OP -- Thank you for your clarifications, it makes the story sound better. It's possible that your care is fine, but that your presentation of overnight events gets so bumbled that people assume that you had no idea what you were doing. For example, you called your senior to help you assess hyperkalemia. That's something I would expect an end of year intern to manage themselves -- unless the patient needs acute HD or transfer to the ICU. So if you can't explain clearly what you did and why, I might wonder whether the senior basically made the decisions. And, as mentioned above, the BV was almost certainly not the cause of the patient's abdominal pain, which resolved on it's own.

From a practical standpoint, you have completed two PGY-1 years. No program is going to continue your training at the PGY-1 level. So the question for the promotion committee / PD is whether you're ready for a PGY-2 position. If yes, then you should be promoted to the PGY-2 level. If not your contract will not be renewed. Any argument you make needs to be that you're ready for PGY-2 responsibilities. based on the content of this thread, I am not certain you're ready for that. Failing a rotation in your repeat PGY-1 is a huge red flag -- after 12 months of experience, you should not be failing rotations.

Of note, your program has been very generous -- I extend PGY-1's who are not ready for PGY-2 by 6 months. If they are not ready for promotion to the PGY-2 by then, their training ends. Honestly, I think this is more fair to them, and gives them time to look for a new PGY position.

On the rotation that I failed, I had 3 attendings pass me. 1 failed me despite verbally telling me he passed me. When I confronted the PD, he said "it could have gone either way." I have objective data to show that I should have passed, but somehow the overall verdict is I failed. I was baffled by this. There are a lot of things that have happened like this. Maybe I'm wrong in thinking that this is unfair. Perhaps this is a common practice. I think there has been at the very least, an anchoring bias towards me. Quite honestly I wish I had not repeated my intern year and did my best to move forward. At least, if the same thing happened, I would have more time to look for another position or figure something else out.

I will also point out, after looking closer at the past 5 years, at least one resident has left the program each year.

What are the key things that you are looking for in residents who are ready for PGY-2?

I am trying to do an M&M on my situation.

 

[atillius]

I mean they already made him repeat intern year and he "failed" a rotation in his repeat year.

There is 0% chance the Evals are all glowingly positive. Failed rotation pretty much guarantees a negative eval.

You are right, they are not all glowingly positive. There are huge disparities between attendings. They all do state that I am improving in the areas that I have been directed to. And in the rotation that I failed, 3 attendings passed me, 1 attending (the PD) failed me. I ended up with a failing grade.

 

[oldanddone]

You're dealing with confirmation bias on the part of the programme director, and negative bias in forward-feeding. when folks know you have a reputation as weak with clinical reasoning, they are more likely to 'see' it.

Now, let's say you do have weak clinical reasoning. Has there been a reasonable attempt to remediate you? Or have you just been given more time, but no guidance? If you knew how to get better i'm sure you would, and it is the responsibility of educators to know how to guide you. typically, this does not happen in medical education too well - not a lot of solid training in teaching. barely a sense of what it is that is getting evaluated in 'clinical reasoning'. you may have an argument here for a further trial extension, that is developed in a way that is solid remediation. there is growing literature on how to remediate various deficits. i will link:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641019/

http://www.ncbi.nlm.nih.gov/pubmed/23597111
that is full text.

another excellent article "remediation of the deficiencies of physicians across the continuum from medical school to practice: a themative review of the literature' by hauer et al in academic medicine, vol 84, no `2, 2009.

if you got through med, the brain is capable, but the approach needs guidance which you haven't gotten. sure, most will figure it out on their own, but i don't see why anyone should be left behind on this kind of thing, when it just takes some advanced teaching skills. at least you should have a coach/tutor who is not in any way connected to your grading, who can help you review feedback and design ways to integrate it. did you have that? if you didn't, perhaps that is something to say maybe should have been there before just cutting you loose.

if you have access to an ombudsman/union rep via a residency organization/any other kind of person who holds an office of advocacy in residency organization/anybody who can be an advocate and can pull weight in the process, you need to get in touch with their office now.

that's my thoughts reading your thread.

 

[atillius]

I did not have anything like that. I had faculty monitor me one on one to see how I was performing. I would follow their advice. It showed in my evaluations. I was never told verbally or on paper that I was not performing/improving up to the expected level through the remediation process. This is what I find so frustrating. I was and am willing to do everything it takes. I have not had any professionalism issues. I have actually been complemented repeatedly on my professionalism. I have been complemented on my medical knowledge. I just cannot see where they are coming up with their overall evaluation.

 

[oldanddone]

It's a relatively new thing to be evidence guided around designing effective remediation. You need somebody with clout in your corner to advocate for it. I hope you can find a person who holds an advocacy role at your institution or residents association who can help petition for such a chance. All the best. There is a stigma around remediation and a tendency to blame the person failing. Remember there is a system around you that is failing to help you even though it is doable based on evidence and methods in the literature. I hope you will be given the chance to learn and shine. And that your programme will take the chance to develop expertise in re mediating successfully. All the best

 

[candbgirl]

When is your meeting?

 

[atillius]

Meeting has come and gone, they contemplated the recommendations, but I am told that it is not going to be in my favor. Not unexpected. I am just trying to decide whether I let the program off the hook and resign, or pursue appeals.

 

[oldanddone]

given how hard it is to get second residency (confirm that) politely appealing may bethe best option if you find people to be in your corner like an ombudsman or dean that responds to this kind of thing. seeing as leaving isconsidered to be a red flag and known to be euphemism for fired. have a plan for what needed to be done differently for successful remediation. those advocates could also be references for second residency and make a damning letter from first pd less likely if they are involved...umpires to make sure everyone is playing ball by the rules

 

[dozitgetchahi]

Agreed. Good question.

 

[NotAProgDirector]

There isn't much of a logical difference. Most forms I complete ask if a person was fired, or whether they resigned in the face of disciplinary problems, etc. But:

1. If you resign before things get bad, then you truly can say you simply resigned instead of getting fired.
2. If you resign and don't have an appeal, your PD may be "happier". That may translate into a better recommendation / better "vibes" when someone calls. Maybe. Also it could be seen as a sign of insight into the problem.
3. If you resign, you (probably) can't collect unemployment. This is very state dependent.

Ultimately it may not matter as much as suggested on this thread. Plus, there's a big difference between requesting a GME run appeal and being polite / professional through the process, and hiring a lawyer and starting a lawsuit. The latter will result in a recommendation stating "This resident completed training from X to Y and left they program. I cannot comment further due to pending litigation at the advice of my lawyer" which will raise all sorts of red flags.