Contract nonrenewal

[cheldrin]

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It’s been a while since this happened. I am looking for thoughts about what has happened. I’m an intern in a university-affiliated program.

In January, I had a meeting with my PD and found out that my performance was not good and needed to be improved, based on evaluations from inpatient medicine attendings. In February, I received an official letter that I would not have a renewed contract for next year. I didn’t even have time to show whether would be able to improve between January with notification of what needs to be improved, and February with notification that I could not continue in residency because of the deficiencies noted in January, because I had not had an inpatient medicine rotation during that time. What’s worse is there was no remediation offered. I have heard that at other places, and also have read about on SDN, residents can have their contracts extended for extra rotation months in what gave them difficulty. Yes, I heard that during this time they are watched very closely during the remediation months, but that is no different than what is happening to me now anyway on all rotations. I would think the benefit of contract extension would be that the resident would have a better opportunity to improve (for residents who take ownership of the negative evaluations and who actually want to help themselves). They would have more time to improve. Not offering remediation or probation (or whatever programs decide to call it) before deciding on contract nonrenewal seems unfair from where I am sitting, but maybe there are program directors out there who see differently. Maybe it’s easier to let residents go? Is it a lot of work to arrange remediation? What other steps are involved in this? Over the last several months I have spent a lot of time and energy in meetings with faculty. Surely there is some imbalance of attention that program directors have directed toward residents who have academic difficulty, so it may feel like the resident is making "more" work for the program director. Is there any ACGME requirement for programs to offer extra academic help to those who are struggling? Where do programs find a good balance between trying to help a person succeed in the field that the resident matched to, or otherwise working to help them find a new program.

I can't see that residents (myself included) really are trying to do poorly in their programs. It would be nice to be offered a good chance at improvement before having a contract nonrenewed. I guess what I'm trying to say is I wish that well meaning residents would still feel welcome in their own program. Maybe it is fair to let people go after a year if they can't cut it. I'm too close to my own situation to really know what to think.

 

[mickey1t]

Dude this really sucks. Unfortunately I have never had any close friends be not renewed, or even have it threatened. I have heard of it happening, but typically to people who obviously do not belong at the program. My best recommendation is to go discuss this with your PD and attendings. If they see you are willing to take ownership of your deficiencies, they may be more likely to loosen their stance.

If you really what to be there, fight for your stop and try to prove to everyone you are willing to do whatever is necessary to improve ourself and in turn be an asset to the program.

Good luck and keep us updated.

 

[BlondeDocteur]

We'll wait for the final answer from AProgDir, but I think the unfortunate answer is that you are not entitled to formal remediation. Your contract can be terminated at any time, "with cause" or without. You would have recourse legally in the latter situation but not the former (and for residents, in our incredibly asymmetric power dynamic with the residency program, even that is doubtful).

I think a great deal of it depends on the caliber, location and general desirability of your program. At both ends of the spectrum I fear programs would have little incentive to extend special courtesies to a failing resident. A very desirable program might feel they could attract a stellar transfer resident easily; a program with a "warm bodies to do scut" approach would take anyone desperately searching for a spot.

At any rate best of luck to you in the next stage!

 

[dragonfly99]

Wow. Sorry that happened to you. That's kind of a tough hit to take. It seems that the program had already decided by January that they were going to not renew your contract, and the meeting with you in January was probably just a formality. There may be something in their GME handbook, etc. that says that you'll get 4 weeks notice to improve, or something. They obviously by this point weren't willing to invest any more in you, for whatever reason.

You seem to be well spoken and to have insight into all this. My opinion is that now it's best to go into damage control mode. It seems like they have made up their mind to not keep you. I think if I were in your situation right now I would be looking for 2-3 friendly faculty members from whom you could get a letter of recommendation to go somewhere else. Your other option is to go back to your program director, grovel more, and hope he agrees to take you back. However, given what you've stated, I think that will probably be low yield. I think that while collecting your LOR's, you should try to find out from any friendly faculty members what they think went wrong with your internship. I doubt this was all your fault, but since the program is not firing everyone there was definitely something going on. Sometimes part of it is just that a particular PD or faculty member(s) doesn't take a liking to a particular trainee's personality. However, if your knowledge base wasn't good, or you get too anxious, or just didn't appear confident enough, or didn't get along well with other trainees or nurses, that could be a reason for nonrenewal too.

Do you want to tell us what specialty you are in, and whether you are US allopathic/DO/IMG or FMG grad? Those things might affect your ability to get a new spot.

I've known of a couple of people who did not get renewed after intern year, and who switched to other specialties and did fine. Getting a new spot can be a struggle though, as your old program may tend to bad-mouth you. One acquaintance managed to wrangle some sort of letter from the progrma that was sort of neutral, and got a new spot in another specialty at a good place. However, this person was a US grad with very high board scores and going into a not that competitive specialty.

 

[Ludicolo]

OP – sorry this happened to you. I agree w/ dragonfly, seems like they already made their decision about you before the January PD meeting.

According to the common program requirements, as per the ACGME, there is an implicit understanding that a program must provide remediation. The structure and depth of remediation however, is unfortunately vague and differs from program to program. Did your attendings go over your evals at the end of each rotation? Did you know you were in trouble? If that was the case, your PD should have met with you earlier. At the January meeting, your PD should have given you a plan for remediation, with a clear timeframe and goals. If you think there is an issue, you are entitled to due process in any case. But, as BlondeDocteur implied, it would probably be very uphill battle.

The type of remediation would also depend on what deficiencies were identified during your January meeting. Was it a problem with your medical knowledge or skills? Was your documentation consistently tardy/incomplete? Were you always late/absent for meetings/lectures? Were there communication or professionalism issues? Yes, it is obviously more work to remediate a poorly functioning resident, but that’s part of the contractual obligation between a program and its residents. IMHO, “Do better or else” does not constitute an adequate remediation plan. If after an honest attempt at remediation a resident still isn’t up to snuff, then their contract shouldn’t get renewed but they should still have the opportunity to look for an open position elsewhere. Unless they are truly incompetent and dangerous.

Additional questions: what have you been doing between February and now? Will you finish the year in good standing? Have you been looking for a different PGY2 position, and what has your PD done to help with this, if anything?

 

[cheldrin]

I'm a US allopathic grad. I'd rather not name the program type. I've thought about transferring to a new specialty altogether (to train in a field that I could be a successful resident in across the board), but when I try to do that I have difficulty picturing myself in a different field.

I've had many meetings, worked with various people/faculty to address the deficiencies, but there has been no "formal" remediation; no one is monitoring what I've done about addressing the deficiencies. Most of this has been self-directed, with people in the program pointing me in the right direction to get started, but coordinated and arranged by me. I think the main area I needed to work on was clinical skills. This isn't an issue over all rotations, just some. Knowledge base was never brought up as an issue. Now that I've looked through the ACGME policies that are posted on its website, it looks like "remediation" is not well defined.

Dragonfly and Ludicolo both stated that my program had decided on nonrenewal. Do programs that do provide remediation hold off on a nonrenewal notification until the remediation is underway?

How could I go about collecting LORs that are sealed or confidential? If I don't know what programs I'll be sending them to yet? Or is it generally understood that people will have generic letters that the resident is going to have to see in order to send it to other programs?

 

[the fat man]

Wow man, that really sucks what happened to you. I wish I could say I knew what to do to help you.

In my admittedly limited experience outside of medicine, it seemed pretty standard that a struggling at-will employee would be confronted a long time, as in a timeframe of multiple months, before any termination decision in order to get a fair chance to improve his/her performance, as well as regular meetings (monthly if not weekly) with his/her supervisor to actually follow up and receive feedback on his/her attempts at remediation. And this all in the absence of "formal" remediation required by the company's HR--basically just a back-and-forth between employee and employer to improve the quality of work. If your story is accurate, it sounds as though they found faults with you months before your 6-month evaluation but made no effort to help you specifically improve, or even informed you that there were problems, then finally told you that you were struggling and gave you little or no time to improve afterward.

Is it acceptable to get sealed letters from attendings but at the same time have them give you some details about what they are going to write? Sometimes you don't even necessarily need details, just an assurance that they feel strongly enough about you to write a positive LOR. In general someone who won't agree to that probably shouldn't be writing a letter for you in the first place.

Also I hope that your PD is at least willing to dismiss you in a way that will not hinder you from getting a position somewhere else. Any PD who refuses to let you remediate inside the program and simultaneously tries to prevent you from succeeding elsewhere deserves their own special circle of hell that Dante didn't write about. Somewhere within one of the bottom circles.

 

[thedrjojo]

in my future program, this past year there was a PGY4 (surgery) who they were unsatisfied with her ability to evaluate consults... what did they do? they made a special rotation for her during the first 2 months of her PGY4 year where all she did was see the consults during the day... the Interns and Midlevels loved it because it saved them from seeing consults (as did the SubI's) and she got a chance to improve her skills and satisfy the administration. I don't know what went into it to get her to that point, or why they did it like that, but I guess this goes out there to others that not all programs just cut and run on people, and I am sorry to hear about your situation. Best of luck

 

[NotAProgDirector]

I'm a bit late to the game here, and you've already gotten some good advice.

First, there's a difference between what a program has to do, and what they should do.

What do they HAVE to do? Sadly, not much. If a program decides to actually fire you, they must notify you of your deficiencies and give you a chance to cure them. They don't have to help you fix anything, legally it's completely up to you. There isn't a good definition of how long they have to give you, either. And, if they decide to simply not offer you a contract for the next year, it's not clear that any of this applies, since they're not really firing you but actually not re-hiring you for the next year. The ACGME does not deal with individual resident issues. IN fact, the only ACGME rule about this can actually hurt residents -- PD's are supposed to give residents 120 days notice if they plan to not renew their contract. This basically forces me to make decisions by the end of February. Presumably the rule is in place so that you can start looking for a new spot, but you can see that it can force me to make an early decision.

As for what a program can or should do in situations like this, there are many options. Personally, when a resident struggles, I always do something other than simply not renew their contract -- I might extend their PGY-1, or promote them to the PGY-2 but in a "probationary status" (i.e. for 3-6 months to see how it goes), or giuve them elective time to explore other options. I might help them find a new program or field, and if successful then free them up whenever their new contract starts. We do have a formal remediation program -- each resident gets a mentor, may get an Occ Med evaluation, and a specific plan with goals for improvement.

Remediating residents is hard. I can certainly see why some PD's would simply not renew contracts. I personally feel a responsibility to help a struggling resident to succeed. Ultimately, it's their responsibility to improve their performance, but I see it as my responsibility to give them every opportunity to do so, and help keep their career on track regardless.

As for what you should do now, I agree with others that your future at this program seems bleak. You could try to get your PGY-1 contract extended, etc, but if they've already found someone to replace you you're doomed. Best to start looking elsewhere. It's vital that you speak to your PD and see what they will support you for -- a new PGY-1 in your current field, a PGY-2 in your current field, or nothing. Support from your PD can be key in these situations.

 

[pjs]

I agree with much of what has been said and appreciate the tough situation you're in. Here are some additional thoughts: (1) there may be internal GME procedures within your hospital that govern this situation or your hospital may be subject to a union such as CIR that may give you certain "rights" in this situation such as hearings, appeals etc. -- definitely look into this if you haven't already done so -- but be very cautious about setting up an adverserial relationship with your program because you may still need letters of recommendation if you are going to transfer programs; (2) if you have a faculty advisor or have developed good relationships with other faculty members especially "influential" ones avail yourself of their help, I wouldn't underestimate their ability to persuade your PD to give you another chance; (3) be careful about bandying about words such as "probation" you really don't want this on your record -- you may have to report it everytime you apply for privilges at a hospital --"remediation" probably will not have to be reported; (4) whether a program can extend your residency for remediation purposes is often a matter of funding and some programs may not be able to afford to.

Finally, sometimes it is better to just cut your losses and move on. I have seen some residents at my program that had a "slow start" who subsequently significantly improved but were really never able to shake their reputation "as not being very good". If you can get good letters of recommendation, including a letter from your PD that does not do too much damage you really just may want to accept your situation and look for another position and chalk this year up to adjusting to being a resident. I know someone who was in your situation who went to another program and did just fine. I wish you the very best.

 

[DocOneDay1]

Dear OP,

I feel for you. I am in the same boat as you. I was non-renewed at my program in spite of excellent evaluations and support from the associate and assistant program directors. I even had a letter from the remediation chairman at my program that my work performance was outstanding. They have championed me in my search for a new program.

Unfortunately, there is little recourse for a resident who has a program director bent on firing them. The law is hazy in most states, but usually a program as an academic institution is required to provide due process to a resident, i.e., a chance at a formal hearing in front of the DIO (designated institution official) who may also be the GME. The hearing usually consists of physicians picked by either the GME or program director... clearly not in the resident's interests if they have problems with either. The committee then can recommend to the chairman of the internal medicine program what to do. Typically, both you and your pd will have a chance to make a case to this committee.

To request such a hearing, letters must be sent within a specific time frame (usually 60 days) from receiving a non-renewal letter to the PD, the DIO, and the chairman of the program you are in. This may end up being worthless, as typically these committees simply side with a PD then risk a potential political infight with a sitting Program director. Its just easier to get rid of a resident at a program then to do the right thing.

You likely should either try to leave your program to an open PGY2 position ASAP! Or you should try to threaten the dept/PD with legal action to see if they scare at all and will allow you to withdraw rather than be non-renewed; or you should re-enter the Match. (I know, SUCKS.)

Best of luck

 

[Roofie]

I feel for you.

Several points:

Make sure you are not suffering from a form of Stockholm Syndrome. Here you may possibly be suffering from abuse and are "trying to own up" to the "abuse/deficiencies". As you have said you have great support from other physicians, yet your PD just does not think you are fit for his field. There is a disconnect here.

You are told that you have "academic" deficiencies. In medicine, "academic" deficiency could mean anything. It's a catch all phrase that courts give deference to the profession in determining who is qualified to obtain certifications. Unfortunately, it has been abused at an enormous economic cost. You could be academically deficient for standing up for others, pointing out weaknesses, or disagreeing with an attending (paradoxically, courts decisions' that were intended to promote academic freedom have been used to promote academic tyranny). You've probably have done well academically in the traditional sense to have graduated medical school and passed your licensing exams.

Do not fall into the trap where you lose confidence in your abilities because your PD believes you are "academically" deficient. It's just a legal position that he is told to take to make legal action more difficult. It's a term of art. It's why many residents academically deficient in one program move on to another program in the same field and successfully complete the new program. If you remove prestige, most programs teach the same material.

The line of cases that have allowed this situation is basically premised on a court's ignorance of clinical medicine in the traditional academic sense. Yet many of the employment/advancement decisions are based on principles that courts are fully competent to evaluate. A court may not know differential diagnosis, but it certainly knows how to fairly decide when people take adverse actions for traditionally non-academic reasons. These decisions are made by physicians without any legal training whatsoever and possibly no adherence to precedent, thus promoting arbitariness.

 

[brotherman]

I'll chime in on this post. I too, have been in this situation. I agree, it is a difficult position to be in. But yes, it is possible to get another residency. It will be difficult, but in a decent proportion of cases it is indeed possible. I would find a few faculty members who would be willing to support you in your mission of finding a second position. If at all possible, try to get a letter from your PD, a neutral one at least. If you have any questions, PM me.