how common is it to get kicked out of residency?

[stillhere]

i'm a fourth year med student who's applying for IM residency and am kinda nervous about it especially after hearing about how horrible intern year is. and considering that i never did honors work (according to my attendings) during third year, i'm afraid of messing up during residency and getting kicked out. so is that common?

---

Members don't see this ad.

 

[sacrament]

It happens, but you sorta have to be a f**k-up. If you're a f**k-up, then go ahead and worry. Otherwise, there are hundreds of residents out there who never did "honors work" in med school who nevertheless plod through residency successfully. (BTW, you can count on "messing up" during residency. That's why we have a residency training period these days, instead of leaping directly into practice where no experienced folks are hanging around to stop you from killing people.)

 

[3dtp]

It happens, but you sorta have to be a f**k-up. If you're a f**k-up, then go ahead and worry. Otherwise, there are hundreds of residents out there who never did "honors work" in med school who nevertheless plod through residency successfully. (BTW, you can count on "messing up" during residency. That's why we have a residency training period these days, instead of leaping directly into practice where no experienced folks are hanging around to stop you from killing people.)

This is a bit naive. There are programs out there that *brag* about kicking out a resident or two a year. Not because there is anything wrong with the residents, but because the program is malignant. Believe it or not, there are some sad sacks in running programs who are so screwed up themselves with a dash of viciousness in their personality that they take delight in destroying other people's lives.

Mostly you do not get kicked out for "messing up." You get kicked out for political reasons. You piss off the senior resident, or the program director or the hospital brass. They can make you gone even if you're the best resident to trot in the door. I've seen it happen. And if it does, not really a whole lot you can do about it.

Case in point: midwest community hospital fired 7 residents from its IM program in 4 years. That many residents get in that far over their heads? I doubt it. Significantly, of these 7, five managed to get into other residencies, (2 surgery, 2 IM, one rad onc) despite the PD's public vow that they'd never work in medicine again.

So, do your homework, be careful and choose your programs wisely. You'll do fine, but when interviewing keep your ears and eyes open, listen for subtle clues. Be very aware. A malignant program will hide those who will be honest with you. Figuring out in advance which program is good is difficult. If you do find yourself in a malignant program, remember it's only 3 years, keep you head down, your mouth shut and then when you get the certificates and licenses, tell the whole friggin world about how bad the program is.

In the meantime, learn what you can, and keep your helmet on and your head down.

If you find a good program, that's great too. Enjoy life, congratulate yourself for choosing wisely, and when you're done tell the world it was a great program.

Good luck, you'll do fine.


Oh, and ahh sacrament, Where's the evidence? I mean, where's the prospective randomized controlled studies that show that we need 3-7 years of residency post internship to stop you from killing people? APNs are saying just the opposite as they lobby for more independence in practice. And they are proving it in rural clinics.
Where's the beef buckaroo?

There's nothing that I've ever found that demonstrates a GP, with current CMEs is less qualified or competent than a board eligible internist in terms of cost of care, clinical outcomes, diagnostic abilities or less capable of reading Harrisons. You figure board exams are costing around $2500 per applicant, and now with MOC/Recertification that the specialty boards are pushing, x say, 100,000 doctors, makes for a whole boatload of money for the boards, and someone's gotta pay for that, without demonstrated benefit, since the people most likely to be not current are those who are grandfathered. But again I ask, where's the evidence?

 

[8744]

You really have to screw up to get fired, especially in the non-competitive specialties like Family Medicine and Internal Medicine where your program will have a hard time finding a replacement for the funding they get for training you, not to mention losing a cheap warm body.

I betcha' if you checked into it, those seven residents quit and the program director says they were fired to make it look like he's in control. Same thing happened at Duke Family Medicine which lost 9 residents in two years.

Small community medicine programs are not very competitive, often have to fill with FMGs and scramblers, and the fact that the "fired" resdidents were able to find other spots shows you the truth of the matter.

 

[8744]

i'm a fourth year med student who's applying for IM residency and am kinda nervous about it especially after hearing about how horrible intern year is. and considering that i never did honors work (according to my attendings) during third year, i'm afraid of messing up during residency and getting kicked out. so is that common?

"Honors work." Har har. What's that? When, oh when, will all of you folks on SDN get out of that mode where you live and die to please others or for somebody else's subjective evaluation?

You can be a terrific medical student and never "honor" anything during your clinical years, especially if you are not an ass-kisser, have a life outside of medical school, and are visibly unenthusiastic to participate in the usual medical school chicken-****.

 

[sequela]

You can be a terrific medical student and never "honor" anything during your clinical years, especially if you are not an ass-kisser, have a life outside of medical school, and are visibly unenthusiastic to participate in the usual medical school chicken-****.

i cannot remember a more ture statement than this. the clinical yrs are a function of your ability to do face time (to stay around, in the visual fields of the people that matter regardless of how late it is and of course how utterly wasteful it is of your time), suck/lick you name it (essentially all of it), appear enthusiastic and willing (to compromise your learning experience by doing scut work to please a resident who want to lighten their own load) and of course, luck. by luck i mean getting on a team or having an attending that is really good.

basically, the whole thing is a joke. i think the clinial yrs should be pass/fail only because you're either a f**k up or not. everyhting else is entirely subjective.

in fact, and quite sadly, 3rd yr is an introduction to the real world....that it's essentially all politics and that you gotta learn to paly the game.

and if you choose not to, you may not honor. life most things in life, it comes down to what you're willing to sacrifice...

 

[stillhere]

i agree that third year is all very subjective. but just like sequela said about third year being an introduction to the real world and we have to learn how to play the game. you could be a great resident but you still have to make your attendings/PD's aware of that. if you are just doing your work and not really showing an effort or not establishing a rapport they will not like you as much. and then if you make a mistake they probably wont support you. and unfortunately whether or not you will graduate the residency program is up to the attendings/PD's.
it's just like trying to get a good job, people use their connections, they kiss up to people. that is the real world unfortunately and after finishing third year, i just wish i was better at playing the game.

 

[MD'05]

You really have to screw up to get fired, especially in the non-competitive specialties like Family Medicine and Internal Medicine where your program will have a hard time finding a replacement for the funding they get for training you, not to mention losing a cheap warm body.

Respectfully, Panda, I must disagree. 3dtp has it right, piss off the wrong people and you are gone. There is always another warm body waiting in the wings to replace you (or the remaining residents are forced to take up the slack with extra call, etc).

Residency is pretty much a political process. It doesn't matter how much of a ******* you are, if you are well liked (and only let patients die through inaction) you are golden. Otherwise you are just another giant turd waiting to be flushed at the discretion of the PD.

 

[erichaj]

"Honors work." Har har. What's that? When, oh when, will all of you folks on SDN get out of that mode where you live and die to please others or for somebody else's subjective evaluation?

You can be a terrific medical student and never "honor" anything during your clinical years, especially if you are not an ass-kisser, have a life outside of medical school, and are visibly unenthusiastic to participate in the usual medical school chicken-****.

Well, here is one place I agree with you 100%. Honor work. lol.

Who gives a crap is some brown nose doc expects you to do the same.

 

[AmoryBlaine]

"Honors work." Har har. What's that? When, oh when, will all of you folks on SDN get out of that mode where you live and die to please others or for somebody else's subjective evaluation?

You can be a terrific medical student and never "honor" anything during your clinical years, especially if you are not an ass-kisser, have a life outside of medical school, and are visibly unenthusiastic to participate in the usual medical school chicken-****.

Agreed. It won't take you long into 3rd year to recognize that aside from performance on exams (never more than 50% of a grade) evaluations are mostly BS. Out of about 10 I've rec'd so far only one was a well-thought out mix of criticism and praise - with recognition of my strengths and suggestions for overcoming weaknesses. Most of them are some permutation of "you did fine" and a "Pass" or "High Pass."

I worked my butt off on one rotation only to find out that out of the 4 attendings on the team, only one was responsible for evals, and she never sought opinions from the other attendings. I got an HP, and realized I probably literally could have told one of the other docs to go to hell and still would have got the HP...

"Honors work." Sheesh.

 

[sacrament]

Oh, and ahh sacrament, Where's the evidence? I mean, where's the prospective randomized controlled studies that show that we need 3-7 years of residency post internship to stop you from killing people? APNs are saying just the opposite as they lobby for more independence in practice. And they are proving it in rural clinics.
Where's the beef buckaroo?

There's nothing that I've ever found that demonstrates a GP, with current CMEs is less qualified or competent than a board eligible internist in terms of cost of care, clinical outcomes, diagnostic abilities or less capable of reading Harrisons. You figure board exams are costing around $2500 per applicant, and now with MOC/Recertification that the specialty boards are pushing, x say, 100,000 doctors, makes for a whole boatload of money for the boards, and someone's gotta pay for that, without demonstrated benefit, since the people most likely to be not current are those who are grandfathered. But again I ask, where's the evidence?

Hey, if you feel comfortable going out and practicing after your intern year, go for it buckaroo. You're probably itchin' to ditch out of whatever crazy-ass part of the country you're in where residents get fired for wearing white after Labor Day.

 

[pathman2006]

It happens, but you sorta have to be a f**k-up. If you're a f**k-up, then go ahead and worry. Otherwise, there are hundreds of residents out there who never did "honors work" in med school who nevertheless plod through residency successfully. (BTW, you can count on "messing up" during residency. That's why we have a residency training period these days, instead of leaping directly into practice where no experienced folks are hanging around to stop you from killing people.)

I agree. I can think of over 200 residents that I know/ worked with and none of them even came close even when they felt like they deserved it.

 

[lowbudget]

Oh, and ahh sacrament, Where's the evidence? I mean, where's the prospective randomized controlled studies that show that we need 3-7 years of residency post internship to stop you from killing people? APNs are saying just the opposite as they lobby for more independence in practice. And they are proving it in rural clinics.
Where's the beef buckaroo?

There's nothing that I've ever found that demonstrates a GP, with current CMEs is less qualified or competent than a board eligible internist in terms of cost of care, clinical outcomes, diagnostic abilities or less capable of reading Harrisons. You figure board exams are costing around $2500 per applicant, and now with MOC/Recertification that the specialty boards are pushing, x say, 100,000 doctors, makes for a whole boatload of money for the boards, and someone's gotta pay for that, without demonstrated benefit, since the people most likely to be not current are those who are grandfathered. But again I ask, where's the evidence?

Read an article long ago. Looked at characteristics of doctors who got in trouble with the Texas Board or sued or something like that. GPs were up there. They also looked at other things like board certification, IMG status, race of doctors, specialty, blah blah.

I don't remember the citation but it was in Texas Medicine, the garbage magazine of the Texas Medical Association.

 

[lowbudget]

Ah yes. Here it is:
http://www.hsc.unt.edu/departments/familymed/DEAR/documents/news20041001.pdf

It's called "Predicting Risk.." blah blah. But disciplinary action by the Board is really broad and includes things beyond the scope of your question. But just because it's not studied doesn't mean it's not true (triple negative).

Apparently an old conversation too: http://forums.studentdoctor.net/archive/index.php/t-97898.html

 

[Faebinder]

Hmm...

The data is from 1989 to 1998. 9 years... According to the data, approximate disciplinary action percentage in Texas was 8%. Mean of approximately 125 people per year.

There is like almost 100 PGY-1 programs in Texas? (I didn't see the article talking about PGY-1 vs PGY-2 vs PGY-3 disciplining). So it's probably 1 resident per program average.

Don't be the ONE.

 

[sebsvenmdc]

Our PD at our med school told us about an intern that was in danger of getting kicked out. Kind of frustrating stuff to hear when you're at this stage of the game...all of us have sacrificed a lot and taken on a ton of debt!

 

[Keg]

Our PD at our med school told us about an intern that was in danger of getting kicked out. Kind of frustrating stuff to hear when you're at this stage of the game...all of us have sacrificed a lot and taken on a ton of debt!

Way to revive the dead.

Anyway... an intern about to be kicked out... after a month? What could they possibly have done?

 

[Shinken]

Thread...awaken from your four year slumber!!

 

[sebsvenmdc]

Way to revive the dead.

Anyway... an intern about to be kicked out... after a month? What could they possibly have done?

Yeah, I pulled this puppy from the grave after doing a google search to try to find some dialogue regarding interns and trouble in their first year. I don't know exactly why the intern is in a LOT of trouble with the program, but there's the risk of getting the boot. Do you know what I can do in my 4th year of med school to decrease the likelihood of this happening to me? I'm planning on anesthesiology and an intern year that's transitional or IM. So, I need to survive the intern year! I've recently bought the Washington manual and DeGowin's Diagnostic Examination...I was planning to hit those this year in addition to Pocket Medicine. I know that 4th year of med school is supposed to be more chill and fun, but honestly, I'd rather make sure I'm ready for residency. I can't get to intern year, get the boot, and try to pay 140k of debt back another way!

My fund of knowledge is not a problem. I did well on the Step 1 and my shelf scores are solid (80s), but I struggle clinically. Charts are huge, so much information, figuring out what to do, and MAINLY, the time factor...it takes me to do long to do H&Ps. Right now, I can afford to use time more elastically, but come intern year, I'm concerned that my inefficiency will catch up with me.

Solution? Practice as much as possible and do several IM rotations, right? Anything else? Any advice would be appreciated! Thanks!

 

[ccfccp]

The truth of the matter is ALL med students are inefficient (well, the overwhelming majority...) It's part of the process. Part of gaining efficiency is seeing enough patients to know what is, and what is not important. This just takes time and practice. Doing more IM rotations as a 4th year could possibly help this (if you think you're REALLY REALLY slow...) but on the whole, you just have to remember it's a process. If you're anything like me, and like most residents I know, you'll be amazed at the rate at which you gain knowledge and (maybe more importantly) comfort level in your chosen specialty. If you've got a good knowledge base, and you're obviously showing concern for this issue, that's a good sign. It's the people who think they're the best (and aren't) that usually run into problems.

As is being discussed on, the way to get thrown out is not usually through incompetence (although it happens.) It's usually getting on the wrong side of administration or some other interdepartmental politics.

 

[Arcan57]

Way to revive the dead.

Anyway... an intern about to be kicked out... after a month? What could they possibly have done?

Not showing up works. In residency, there was a guy the year before I started that didn't get the whole "you have to show up on time (or at all) for your shift". He lasted ~3 weeks before being terminated. Of course, he was pulling down big money from some software he developed as a med student.

 

[Law2Doc]

Not showing up works. In residency, there was a guy the year before I started that didn't get the whole "you have to show up on time (or at all) for your shift". He lasted ~3 weeks before being terminated. Of course, he was pulling down big money from some software he developed as a med student.

From what I've seen, the fastest way to get thrown out is to make stuff up. If an attending asks you a question, and you don't know the answer, don't "guess", don't make crap up. Simply say "I don't know, but I'll go check". Yes, you might get berated. The attending might get annoyed with you. But if you make up a lab value or say the patient is urinating fine, etc, and it turns out you are simply making crap up because you don't want it known you didn't check, that is probably the quickest path out of residency. And you see folks getting into this kind of mess time and again. The ideal is to know everything about your patients. But when you don't, always, always admit that you "need to check", don't fake it. Faking it gets you kicked out of programs.

 

[doctorFred]

Thread...awaken from your four year slumber!!

 

[gutonc]

Solution? Practice as much as possible and do several IM rotations, right? Anything else? Any advice would be appreciated! Thanks!

There are 2 very simple rules to follow in order to avoid getting into trouble as an intern:
1) Be competent

You don't have to be the greatest physician to ever walk the planet. What you need is to have a fund of knowledge consistent with your training level, the ability and willingness to increase that fund of knowledge and the common sense needed to implement it clinically. This doesn't mean you have to know every answer all the time but it does mean that you need to know when you don't know the answer and how to get it.​

2) Don't be a douche

This is a little less straightforward than the above, but may be more important. Remember that every single person you interact with during your time at work is both worthy of a basic amount of respect, and capable of making your life difficult in some way. You have something to learn from the nurses, the RTs, the dietitians, the pharmacists, the CNAs...basically everybody. Respect their knowledge base and they'll respect yours. The attitude of "I'm the doctor so you'll do what I say" is a good way to get in trouble. This doesn't mean let people walk all over you, or follow bad advice when you know better but you need to be civil when responding to bad advice or other issues.​

I've only seen a couple of residents not get their contracts renewed and both of them failed both of the above tests.

 

[turquoiseblue]

i'm a fourth year med student who's applying for IM residency and am kinda nervous about it especially after hearing about how horrible intern year is. and considering that i never did honors work (according to my attendings) during third year, i'm afraid of messing up during residency and getting kicked out. so is that common?

i know there were 280 kicked out in 2008....i dont know the rest of the years though....a few years ago the numbers trended around 200 according to some article i read a long time ago, which I haven't been able to find again.

most likely you won't get kicked out. that is a small fraction of residents. just do your work, try to do well, be on time, and you'll be fine. sometimes people with better credentials than you can get kicked out. just be careful and prove yourself in your program.

 

[sebsvenmdc]

Thanks for the responses, guys. So, I definitely get the points about not making stuff up, not being a douche, respecting others, etc. Those are great - thanks for pointing them out. Those are things I will keep in mind when I start next Fall. So, with about 11 months to go before I get there, what is the best way to improve the competence component. My fund of knowledge is great (great Step 1, good shelves, and I read a lot)...but I find it harder to keep up with patient care in the hospital. So, it's clinical competence regarding keeping administrative things clear, physical diagnosis skills, H&P skills, and efficiently dealing with the information surplus. So, I can maximize practice by working as hard as possible in the hospitals, and maybe by going through my resources: Washington Manual, DeGowins, and Pocket Medicine...and using the Step 2 CS book to stay sharp with DDX? My heaviest patient load has been like 4! And I wasn't writing orders and barely keeping up. That could be up to 10 as an intern!

 

[dragonfly99]

sebs,
unlikely that you'll get kicked out of residency, so don't spend too much time obsessing about that.
I agree w/your plan of doing several clinical rotation this year in which you are taking care of patients (things like IM, ER, perhaps surgery). Definitely you want to do an ICU month. I don't think it matters that much if it is MICU or SICU. If you want, you can wait until further along in the year so that you don't have to worry about the grade on your transcript if you want to take rotations that are known to grade lower. Radiology can also be a helpful rotation. Handling 4 patients as a 3rd year med student actually is not bad, or even for 4th year. If you keep working at it, you'll get there clinically. One thing you find out when you are an intern is that you just can't do a superdetailed H and P an on every patient to the level of detail that you are taught as a med student...if someone comes in who is just really acutely sick or just has a very obvious diagnosis (like trauma, sepsis, etc.) sometimes you have to do a brief H and P,start treating the patient, and then come back later or the next day and get more information from the family or patient. It may not matter the occupation, whether the patient smokes 1 or 1.5PPD cigarettes,etc. You have to learn what information is truly important for that patient in order to do stuff faster but still not miss important details.

Last, I think it's important not to burn out before intern year. You should leave yourself some easy rotations in there somewhere, especially near the end of the year and/or when you are doing residency interviews.

 

[turquoiseblue]

Thanks for the responses, guys. So, I definitely get the points about not making stuff up, not being a douche, respecting others, etc. Those are great - thanks for pointing them out. Those are things I will keep in mind when I start next Fall. So, with about 11 months to go before I get there, what is the best way to improve the competence component. My fund of knowledge is great (great Step 1, good shelves, and I read a lot)...but I find it harder to keep up with patient care in the hospital. So, it's clinical competence regarding keeping administrative things clear, physical diagnosis skills, H&P skills, and efficiently dealing with the information surplus. So, I can maximize practice by working as hard as possible in the hospitals, and maybe by going through my resources: Washington Manual, DeGowins, and Pocket Medicine...and using the Step 2 CS book to stay sharp with DDX? My heaviest patient load has been like 4! And I wasn't writing orders and barely keeping up. That could be up to 10 as an intern!

Usually, in the first month of residency, they will let you off the hook and don't expect much because they know you just started and are learning. eventually they get a little more strict as time goes on and expect more.
you shouldn't worry too much because there are other interns that will be working with you in your same boat, so the PD has to understand that and they usually do. residency is a step by step process. You're not usually expected to know everything from the start, just expected to keep improving along with your peers. if you really want to get the intern experience, do a sub-I rotation in your desired specialty somewhere to get a feel for it.

 

[lipomas]

SDN reasons for getting kicked out of residency:

1) Racial bias
2) Bias against FMGs
3) Bias against non-english speakers
4) Conspiracies of some sort involving slush funds
5) Nurses don't like you because you spoke up once when they tried to cover up a mistake
6) Missing one day of work because you had radical cancer surgery

Real life reasons for getting kicked out of residency:
1) Not showing up after repeated warnings for not showing up
2) Incompetence after several remediation attempts
3) Trying to cover up a major mistake and then failing to admit it when confronted
4) Major league insubordination (like punching an attending on more than one occasion)
5) Drug abuse after failed attempts to correct it
6) Commiting a felony

 

[cartoondoc]

There are programs where residents get kicked out because the PD is extremely malignant and all the residents are basically walking on eggshells. So I think the only two ways to get kicked out of residency is:

1) You end up in a rare mega-malignant program where residents sometimes get kicked out for no good reason.

2) You are a total disaster to the point of seriously endangering your patients (drug abuse, not responding to pages, etc.)

If you're just a below average resident in a run of the mill program, I don't think there's anything to worry about.

 

[sebsvenmdc]

SDN reasons for getting kicked out of residency:

1) Racial bias
2) Bias against FMGs
3) Bias against non-english speakers
4) Conspiracies of some sort involving slush funds
5) Nurses don't like you because you spoke up once when they tried to cover up a mistake
6) Missing one day of work because you had radical cancer surgery

Real life reasons for getting kicked out of residency:
1) Not showing up after repeated warnings for not showing up
2) Incompetence after several remediation attempts
3) Trying to cover up a major mistake and then failing to admit it when confronted
4) Major league insubordination (like punching an attending on more than one occasion)
5) Drug abuse after failed attempts to correct it
6) Commiting a felony

I agree with all of your real life reasons, but I was wondering if you could elaborate on 2). How are residents/interns clinically incompetent? I care about this obviously because I want to try to prevent it!

 

[SouthernSurgeon]

SDN reasons for getting kicked out of residency:

1) Racial bias
2) Bias against FMGs
3) Bias against non-english speakers
4) Conspiracies of some sort involving slush funds
5) Nurses don't like you because you spoke up once when they tried to cover up a mistake
6) Missing one day of work because you had radical cancer surgery

Real life reasons for getting kicked out of residency:
1) Not showing up after repeated warnings for not showing up
2) Incompetence after several remediation attempts
3) Trying to cover up a major mistake and then failing to admit it when confronted
4) Major league insubordination (like punching an attending on more than one occasion)
5) Drug abuse after failed attempts to correct it
6) Commiting a felony

 

[Law2Doc]

There are programs where residents get kicked out because the PD is extremely malignant and all the residents are basically walking on eggshells. So I think the only two ways to get kicked out of residency is:

1) You end up in a rare mega-malignant program where residents sometimes get kicked out for no good reason....

Bear in mind that your so called "mega-malignant" residencies such as this will actually tend to kick out residents for actual articulable reasons -- it's just that those residents (rightly or wrongly) will disagree, and spin their own version where they are essentially blameless. But for legal reasons there will always be a reason for every dismissal. And as there are two sides to every story, and on SDN you usually only hear the dismissed residents' view, it's hard to know if the residency was actually malignant or just painted that way. But no, programs won't dismiss folks "for no good reason", even at a very malignant program. There will always be a reason. Whether it is a good or legit one is probably somewhat dependent on the eye of the beholder.

 

[Darkskies]

I agree with all of your real life reasons, but I was wondering if you could elaborate on 2). How are residents/interns clinically incompetent? I care about this obviously because I want to try to prevent it!

I am just a pre-med but I second sebsvenmdc's question.

 

[dragonfly99]

I do think that sometimes residents get kicked out of residency for really no good reason. There are programs that kick people out pretty much every year...and I don't really think there are that many totally incompetent residents (who could not be remediated) and/or crazy/personality disordered ones. So in that sense there are "malignant residencies", although they are fairly rare.

As far as the competency question, I think the only remedies I can think of are to study hard in med school to achieve a decent level of knowledge, don't totally slack off (but also don't burn yourself out) during 4th year, and then when you become an intern/resident, to just work hard and treat the patients like you would want your family member treated. Don't be lazy...follow up on the little details, labs, tests, etc.

 

[Darkskies]

I do think that sometimes residents get kicked out of residency for really no good reason. There are programs that kick people out pretty much every year...and I don't really think there are that many totally incompetent residents (who could not be remediated) and/or crazy/personality disordered ones. So in that sense there are "malignant residencies", although they are fairly rare.

As far as the competency question, I think the only remedies I can think of are to study hard in med school to achieve a decent level of knowledge, don't totally slack off (but also don't burn yourself out) during 4th year, and then when you become an intern/resident, to just work hard and treat the patients like you would want your family member treated. Don't be lazy...follow up on the little details, labs, tests, etc.

Let's say you have a decent fund of knowledge but are just slow clinically and/or lack common sense. Would this be problematic? I hope I'm not putting words into people's mouths but I believe that's more to what sebsvenmdc is worrying over(at least that is the case for me).

 

[Winged Scapula]

Let's say you have a decent fund of knowledge but are just slow clinically and/or lack common sense. Would this be problematic? I hope I'm not putting words into people's mouths but I believe that's more to what sebsvenmdc is worrying over(at least that is the case for me).

Absolutely.

As a matter of fact, I would venture that residents lacking "common sense" or having trouble getting their work done is a more common reason for termination than fund of knowledge issues.

I personally know 1 resident who was terminated despite having near perfect in training scores - very bright guy (on paper) but couldn't work up a patient, couldn't come up with a differential without taking hours to do so, and was very disorganized. The final reason for termination was more involved but the above issues certainly put him "on radar".

 

[Darkskies]

Absolutely.

As a matter of fact, I would venture that residents lacking "common sense" or having trouble getting their work done is a more common reason for termination than fund of knowledge issues.

I personally know 1 resident who was terminated despite having near perfect in training scores - very bright guy (on paper) but couldn't work up a patient, couldn't come up with a differential without taking hours to do so, and was very disorganized. The final reason for termination was more involved but the above issues certainly put him "on radar".

Scary! Is there any way to address these issues if one has them?

 

[lipomas]

I agree with all of your real life reasons, but I was wondering if you could elaborate on 2). How are residents/interns clinically incompetent? I care about this obviously because I want to try to prevent it!

It's usually obvious when you see it. Although it may not be obvious at all to the incompetent resident. That's often the main problem. It often involves continual behavior that goes against what has been taught - like continually failing to order the right tests or something like that. I am in pathology - incompetent residents I have seen are ones who cannot make simple diagnoses despite being told many times why and how their impressions are incorrect (i.e. they never improve). Others have tried to cover up mistakes they made in processing specimens, or have done a poor job of processing specimens and been told exactly what they should be doing differently but then they don't do it.

An example of the latter from my residency: Resident X was on service with me and received a complicated surgical resection specimen. I told resident X, who would be grossing in the specimen (describing it, taking tissue sections for slides, etc) that he/she should go over the specimen directly with the attending because the attending will be the one who has to sign the case out and since it is a complicated case they can go over it with them. So the resident did this, but then proceeded to not take the attending's advice, did it his/her own way (which was truly messed up) and the correct diagnosis and staging of the tumor was only obtained through shear luck. Said resident then proceeded, next time he/she got a complicated specimen, to not show anyone and guessed how he/she should do it.

I am sure clinical residents have similar stories - like residents who are told how to work up chest pain but then failing on several occasions to order certain tests.

I don't disagree that there are, as dragonfly said, occasional residents who are kicked out for less than great reasons. But my point is that these residents are very much in the minority.

 

[Faebinder]

Altered Beast!!! Wow it's been ages!! hahaha

 

[turquoiseblue]

i was called out for not calling my seniors....they were mean whenever i called them as if i shouldn't, and i didn't know any better, so i figured maybe i should try to figure it out myself and not call them unless i really need them...but it turns out that is a big part of residency--calling your seniors....so definitely do that and double check everything so you can never mess up. it will make your life easier.

also document everything you do into the chart so no one can tell you that you didn't do a certain thing..it is very important...or they could also call you out for not documenting, so do that too!

be nice to nurses, because they can screw you over like you never knew......one nurse reported me for leaving a needle, when i was coming back to the room. she didn't like me....she made it such a big issue that it ruined me....not to mention some other nurses there...you have to be on their good side because especially at community hospitals, they know people in high powers and can get them to do whatever they want them to do....scary and unbelievable, but true, even other nurses warned me of the powers they had...they also are involved in grading you i think in some hospitals...so watch out in dealing with them...be very careful...bring goodies...

never ask a nurse supervisor to help you deal with problems with a nurse, always call in a senior resident to handle it. i learned the hard way.

small things like these can screw over your career for good, even if you dont know any better. just know how to be a resident and what to do and when to call for help. that is key.... especially for IM, because they are very nit picky and paranoid in that field, and hold you accountable for your every move.

 

[anon-y-mouse]

i was called out for not calling my seniors....they were mean whenever i called them as if i shouldn't, and i didn't know any better, so i figured maybe i should try to figure it out myself and not call them unless i really need them...but it turns out that is a big part of residency--calling your seniors....so definitely do that and double check everything so you can never mess up. it will make your life easier.

What did you call your seniors about and what didn't you, that you feel you maybe could have?

 

[Roofie]

It's definitely not uncommon. About 1100 residents get eliminated each year without a spot for the following year; effectively, ending their careers. About 22809 designated PGY-1's enter the system each year. So about 1 in 20 MD's who land a core residency never finish it.

It's really funny that a person losing a 60k house has more procedural protections than a PGY I. He has spent 200k for 8 years of schooling and the state/feds have spent about 150k for that first year of training. The numbers get more ridiculous for upper level residents and fellows.

It's really funny, that in the name of judicial efficiency, courts would give almost absolute deference to programs in making traditionally employment decisions rather than traditionally academic decisions. The economic loss borne by these residents is in the billions per year and exceed the entire budget of the judiciary department. The procedural and substantive safeguards would probably only cost several thousand per resident for a total cost of about several million per year nationwide.

I hope some sympathetic MD with legal training makes a compelling argument on behalf of the plight of these residents. A good start would be writing a brief on behalf of the IRS against Mayo Clinic. The argument would implore the Court not to classify residents as students but rather employees. It would not be too late if the IRS, a governmental agency, accepts the brief.

The money at stake in that case is chump change compared to a much larger problem that occurs every year.

This case is ideal in that the parties are evenly matched. It won't be David vs. Goliath in the biblical sense rather than the medical sense. Neither side will be able to bury the other with its available resources.

 

[turquoiseblue]

What did you call your seniors about and what didn't you, that you feel you maybe could have?

Mostly for emergencies....or noting unusual findings right away. for example, one morning, before my seniors even came in, I noted a patient who was tachypneic but appeared to be sleeping, and not very arousable....i was about to tell my senior about it but i should have told her or some other senior who was available right away, instead of during rounds. it turns out the patient was seizing. i had never personally witnessed a seizure so i didn't know...i thought he was just sleeping but i did tell her about the tachypnea, and my senior reported me for not telling her earlier.
apparently the patient was in DT's and needed immediate transfer to the ICU.
it was scary because this was within my first month of being there....it was a hospital full of surprises and emergencies with high patient load.....not an easy going hospital at all...

one time i was told to check on a random patient's abg results. i had many other things going on at the same time so i got to it a little later than i should. turns out they found out that the patient was having a pulmonary embolism...they got mad at me for not calling them immediately with results...this was my first incident in not calling my seniors..i didn't know i had to call them at that time...i didn't know they expected me to do that...

i think it was just my luck to run into the worst emergencies possible....and not know the rules of residency..at another program it was so laid back in comparison...

 

[odieoh]

It's definitely not uncommon. About 1100 residents get eliminated each year without a spot for the following year; effectively, ending their careers. About 22809 designated PGY-1's enter the system each year. So about 1 in 20 MD's who land a core residency never finish it.

Where are you getting your numbers from? If you are counting prelim positions then its really not accurate to say they were "eliminated," they knew they weren't going to have a spot the following year when they signed up. And actually most of them DO have a spot for the following year, just at a different program. Certainly not accurate to say "effectively ending their careers." Even if a resident is actually terminated it doesn't necessarily end their career, though its not helping it any. Many who are terminated are able to get a fresh start at another program. Certainly there are those who don't, but it is nowhere near 5% of residents.

 

[rph3664]

At the hospital where I worked for 7 years, the only resident I knew of who was expelled from the program was probably the best one we had in the program at the time.

And he was arrested for and convicted of domestic violence: he beat up his wife.



There was another resident who should have been expelled. She had serious mental health issues (we're talking multiple hospitalizations) but they couldn't kick her out because of the Americans with Disabilities Act.

 

[turquoiseblue]

I hope some sympathetic MD with legal training makes a compelling argument on behalf of the plight of these residents. A good start would be writing a brief on behalf of the IRS against Mayo Clinic. The argument would implore the Court not to classify residents as students but rather employees. It would not be too late if the IRS, a governmental agency, accepts the brief.

The IRS considers residents employees while medical colleges mandate them as students. http://chronicle.com/article/US-Supreme-Court-Agrees-to/65738/

if we consider residents as employees it makes it easier to kick them out, right? unless you meant the opposite of what you wrote?

 

[Roofie]

Where are you getting your numbers from? If you are counting prelim positions then its really not accurate to say they were "eliminated," they knew they weren't going to have a spot the following year when they signed up. And actually most of them DO have a spot for the following year, just at a different program. Certainly not accurate to say "effectively ending their careers." Even if a resident is actually terminated it doesn't necessarily end their career, though its not helping it any. Many who are terminated are able to get a fresh start at another program. Certainly there are those who don't, but it is nowhere near 5% of residents.

Thanks for correcting me. From NRMP Match data 2010, 22809 represents the total number of PGY-I. This number includes 3028 undesignated prelim positions in medicine and surgery. The denominator should then be 19781. This represents the number of MD's entering the pipeline with a reasonable expectation of completion of some program.

From ACGME 08-09, 258 residents were dismissed from core programs while 863 withdrew without a spot in the following year. Most likely, these residents are eliminated from the pipeline. This 1121 number does not include a larger number of residents who were able to transfer.

Therefore 1121/19781 = 5.67%. This is a rough estimate of the number of MD's who never finish a core residency.

The dispute is whether the dismissal or withdrawal was legitimate or illegitimate. Procedural and substantive safeguards would reduce the number of illegitimate dismissals.

 

[anon-y-mouse]

Mostly for emergencies....or noting unusual findings right away. for example, one morning, before my seniors even came in, I noted a patient who was tachypneic but appeared to be sleeping, and not very arousable....i was about to tell my senior about it but i should have told her or some other senior who was available right away, instead of during rounds. it turns out the patient was seizing. i had never personally witnessed a seizure so i didn't know...i thought he was just sleeping but i did tell her about the tachypnea, and my senior reported me for not telling her earlier.
apparently the patient was in DT's and needed immediate transfer to the ICU.
it was scary because this was within my first month of being there....it was a hospital full of surprises and emergencies with high patient load.....not an easy going hospital at all...

one time i was told to check on a random patient's abg results. i had many other things going on at the same time so i got to it a little later than i should. turns out they found out that the patient was having a pulmonary embolism...they got mad at me for not calling them immediately with results...this was my first incident in not calling my seniors..i didn't know i had to call them at that time...i didn't know they expected me to do that...

i think it was just my luck to run into the worst emergencies possible....and not know the rules of residency..at another program it was so laid back in comparison...

I'm sorry, that does sound like terrible luck. The resident seems ultimately more responsible, so I am surprised they didn't check that stuff out for themselves.

 

[JelloBrain]

I noted a patient who was tachypneic but appeared to be sleeping, and not very arousable....

one time i was told to check on a random patient's abg results. i didn't know they expected me to do that...

ABGs are always ordered when someone's seriously ill-you have to be eagerly waiting to get the results and act on them ASAP!

Tachypnea+non-arousable patient-call for help ASAP.

I have great sympathy for your case, however it looks like you didn't know how to prioritize. That is surprising to me as most of 4th year is spent in clerkships where you learn all these things AFAIK.

Anyways good luck with your future endeavors.