Hi everyone, I am a PGY-1 who was recently dismissed from IM program due to academic deficiencies. I am going through a really hard time and I think it's appropriate to share my situation so people with more experience than me can give some more insight and advice. This is going to be a very honest and detailed long post and the narrative it's going to be in chronological order. I know I may be at risk of being identified but I believe this is an open and collaborative community created to help each other and I want to believe people won't gossip or rejoice on the misfortune of others.
I started internship last July, before that we underwent a SIM case so the program could get a sense of our medical aptitudes, as a result, some people will be starting their internship under indirect supervision, others (me) were deemed to be placed under direct supervision meaning our resident needs to be shadowing every single move we made.
First call block I was completely lost in the system, I shortly realized that my previous experiences and background didn't quite prepare me for this (I am an IMG with extensive research background in the US but no further clinical experience in this country, very good board scores) I worked really hard, remember I was arriving very early (~5-5:30am) to read about patients and have everything prepared for rounds. I could sense the stress of my resident for having an intern on direct supervision, I was trying to be efficient but it took me forever to finish my notes on time and keep up with the pace. My resident was not very kind to me, he/she would yell at me in front of others, made me cry and usually pimp on me during rounds in front of the attendings (all of them were very nice and understanding that I was just an intern in his first call block) My resident gave me a terrible evaluation, basically I was scored the minimum in all the core competencies and he/she wrote that he/she would never let me take care of any of his/her family. My attending gave me a pretty average evaluation pointing out the areas for improvement which I carefully read. At the end of the block I was called by my PD to let me know I was placed on remediation, they changed my schedule and made me repeat the rotation. The feedback they got from me was concerning for knowledge fund below average, lack of accountability in the care of patients (forgets to track down results), that I was defensive to feedback (which I don't fully understand, I treated my resident with the uttermost respect and never disobey or ignore him/her, but again, this is my perception, we both come from a different countries and there may have been some cultural differences and maybe even a personality issue) and an issue with professionalism (it was said that I was falling asleep on morning reports after night shifts and that I was using social media during the conference which I remember I did a couple of times because I couldn't help falling asleep!) This time I was determined to make it work. I had a very nice resident that walked me through everything and I could see myself being faster, more efficient and things were improving. My program lifted the remediation with a note that I should continue working on knowing every aspect of my patients and accountability with patient care (it was noted that I was not placing many orders), I got nice evaluations from my attending and even a praising award for teaching and sharing some of my research knowledge in the monthly journal club. Next block, I was on floors again at a different hospital, I had an excellent resident and things were going well, I had a very busy night when I admitted a patient with hyperactive delirium, the case was very challenging and my assessment was complicated by her combative behavior. I identified a glucose value of 65 taken 3 hours before on the ED. I precepted the case with the attending on call who encouraged me to act promptly when I face critical lab values without waiting to check with him. I run to the nurse asking for a repeated value, this time the patient’s glucose was 47 and I immediately put an order for hypoglycemia protocol. After the attending evaluated the patient he told me to order Haldol; my concern at that moment was the lack of an EKG. I remembered some studies shown that olanzapine is safer to use since it has minimal effects on cardiac repolarization compared to Haldol. The attending was receptive to my suggestion and instructed me to order olanzapine. I independently looked up the dose for agitation on UpToDate and read 10 mg. In the middle of a hectic night, I made the mistake of not double checking the dose with the attending and I didn’t read further for geriatric considerations either. I put an order for Olanzapine 10 mg when the attending found out he freaked out and instructed me to see the patient, she was HD stable and arousable but by the end of the night she was obtunded and a rapid was called. I was placed on administrative leave after that and instructed to meet my PD. He basically told me there is a rising concern for me not being able to identify critical values and not reacting promptly, additionally the Olanzapine event triggered the concern for patient safety. The CCC recommended dismissal from the program but I had a chance to meet with them, I basically went and explained that I I was very disappointed at myself, I was feeling profound contrition for what happened to my patient and I outlined an action plan to remediate myself. They gave me another opportunity but placed me on a Letter of Deficiency. My next rotation was going to be ICU but they switched it and made me do floors again. Obviously, I was placed under direct supervision. This block was terrifying for me, I was so nervous and anxious all the time, getting in there very early in the morning, chief residents were instructed to be present in my rounds to check on my presentations and thought process, I was barely sleeping or living, I was exhausted and I was also feeling very depressed since I was not allowed to cross-cover during this block. Long story short, the block ended, I progressed from direct to indirect supervision and was ready to move on to my next block (the one I was looking forward): research. However, I was called again by my PD; this time he pointed out that I didn't make enough progress to satisfy the LOD, there were still some concerns for me not promptly reacting to urgent situations (I was faulted because I texted my resident instead of calling her when I identified a patient with hypotension, I gave her fluids and got nurses involved as I was waiting for a reply from him/her but apparently I should have called, I was also faulted because we had a patient with hypoxemia that was in the low 90s when I saw him but otherwise stable, the attending, my resident and me started rounds on a different patient, when we got to this patient they reprimended me for not speaking out and dragging the team to round on this patient first) so they decided to extend the letter for 2 more rotations. By that time I was exhausted, I did 4 floor blocks in a row and I was going to do 2 more! I brought that up and they told me I could do an elective the first month and then floors again. So I did, I was working really hard during my cardiology elective, got really nice evals from the attendings, the only thing one of the electrophysiologists pointed out was that I needed to learn more EKG (which I totally agree with, EKG is not one of my strengths so I bought a book and everything to keep up with that). Last block: floors at the hospital where I began my intenship, this time I super familiar with the system, some of the nurses remembered me and we had a good relationship, I also had really nice residents and everything was going well, I was dedicated to reading about my patients every day, I was putting a lot of effort on my notes (which I was told they were really good) until my week of nights in which one day I was cross-covering and again, got paged for a patient with hypotension, I went to evaluate the patient, check the blood pressure myself, confirmed that she was 70/50, gave her a small bolus (small because she was an ESRD patient) and ask the nurse to page me back, didn't hear from her at all until I got an overhead page (for some reason the text-page didn't go throug), called her back and she told me BP was the same, I immediately contacted my resident and let him know about the situation, we checked the chart, order some labs and ended up transfusing the patient. Next morning I was paranoid, I checked the chart and saw an attending note that the patient improved with fluids and transfusion and discharge was planned for the following day. I felt relieved but again I was called by one of the chiefs, they were concerned about my management, I was told that I should have had my resident involved as soon as I was paged for a patient with hypotension. They told me I am not my own practice and what if, what if, what if, what if this patient crashed. My rotation ended without any other issues. I was called again to my PDs office to talk and I received a letter of dismissal. I was despondent to hear the news, but deep inside me, I knew this was a real possibility. I am lost, feeling that my career is over. My PD explained that the CCC feels they have given me the opportunity to remediate myself and that "the decision was made in light of the tremendous efforts required to produce minimal improvement". Some of the deficiencies outlined in the letter are repetitive like: "reacts appropriately and initiates management in common urgent/emergent situations: not achieved", but some others were new like "complete assigned educational and administrative tasks: not achieved" this meaning that I am not uptodate with submitting my clinical hours or completing blackboard cases (and it is a fact that I was not uptodate but talking to my peers nobody is!). I have requested all my evaluations with the final stats and I score a little bit below the 50th percentile in some competencies and a little bit above 50th in others.
Finally, to complicate the situation, I am a J1 visa holder and this visa is subject to the 2 year restriction, meaning that if I get terminated or resign, I have to go back IMMEDIATELY to my country (yes, 24hrs) and I am not able to apply to a work visa J1/H1 after 2 years of being terminated which means basically that even if I apply to the match this year, I wouldn't be able to start on July 2019.
At this point, I am in the middle of an appeal process, my question would be if this community believes there could be a possibility of reversal. I am also considering the possibility of transferring to a different program (a smaller program perhaps) but haven't found any open spots available as of today. Finally I talked to my PD about the possibility of extension of training (being as deficient as they are telling me I am, I am willing to extend my internship for 3, 6, 9 months if necessary) however they have told me they don't think that could be a possibility because as educators "they are not sure if the gap is going to ever close". I am going through the appeal process very discouraged, however, I also want to explore the possibility of repeating internship year, how common is that? Maybe people with more experience here are able to give me a word or two.
I apologize for the very long post, I really appreciate the people who take the time to read and post a comment.
I started internship last July, before that we underwent a SIM case so the program could get a sense of our medical aptitudes, as a result, some people will be starting their internship under indirect supervision, others (me) were deemed to be placed under direct supervision meaning our resident needs to be shadowing every single move we made.
First call block I was completely lost in the system, I shortly realized that my previous experiences and background didn't quite prepare me for this (I am an IMG with extensive research background in the US but no further clinical experience in this country, very good board scores) I worked really hard, remember I was arriving very early (~5-5:30am) to read about patients and have everything prepared for rounds. I could sense the stress of my resident for having an intern on direct supervision, I was trying to be efficient but it took me forever to finish my notes on time and keep up with the pace. My resident was not very kind to me, he/she would yell at me in front of others, made me cry and usually pimp on me during rounds in front of the attendings (all of them were very nice and understanding that I was just an intern in his first call block) My resident gave me a terrible evaluation, basically I was scored the minimum in all the core competencies and he/she wrote that he/she would never let me take care of any of his/her family. My attending gave me a pretty average evaluation pointing out the areas for improvement which I carefully read. At the end of the block I was called by my PD to let me know I was placed on remediation, they changed my schedule and made me repeat the rotation. The feedback they got from me was concerning for knowledge fund below average, lack of accountability in the care of patients (forgets to track down results), that I was defensive to feedback (which I don't fully understand, I treated my resident with the uttermost respect and never disobey or ignore him/her, but again, this is my perception, we both come from a different countries and there may have been some cultural differences and maybe even a personality issue) and an issue with professionalism (it was said that I was falling asleep on morning reports after night shifts and that I was using social media during the conference which I remember I did a couple of times because I couldn't help falling asleep!) This time I was determined to make it work. I had a very nice resident that walked me through everything and I could see myself being faster, more efficient and things were improving. My program lifted the remediation with a note that I should continue working on knowing every aspect of my patients and accountability with patient care (it was noted that I was not placing many orders), I got nice evaluations from my attending and even a praising award for teaching and sharing some of my research knowledge in the monthly journal club. Next block, I was on floors again at a different hospital, I had an excellent resident and things were going well, I had a very busy night when I admitted a patient with hyperactive delirium, the case was very challenging and my assessment was complicated by her combative behavior. I identified a glucose value of 65 taken 3 hours before on the ED. I precepted the case with the attending on call who encouraged me to act promptly when I face critical lab values without waiting to check with him. I run to the nurse asking for a repeated value, this time the patient’s glucose was 47 and I immediately put an order for hypoglycemia protocol. After the attending evaluated the patient he told me to order Haldol; my concern at that moment was the lack of an EKG. I remembered some studies shown that olanzapine is safer to use since it has minimal effects on cardiac repolarization compared to Haldol. The attending was receptive to my suggestion and instructed me to order olanzapine. I independently looked up the dose for agitation on UpToDate and read 10 mg. In the middle of a hectic night, I made the mistake of not double checking the dose with the attending and I didn’t read further for geriatric considerations either. I put an order for Olanzapine 10 mg when the attending found out he freaked out and instructed me to see the patient, she was HD stable and arousable but by the end of the night she was obtunded and a rapid was called. I was placed on administrative leave after that and instructed to meet my PD. He basically told me there is a rising concern for me not being able to identify critical values and not reacting promptly, additionally the Olanzapine event triggered the concern for patient safety. The CCC recommended dismissal from the program but I had a chance to meet with them, I basically went and explained that I I was very disappointed at myself, I was feeling profound contrition for what happened to my patient and I outlined an action plan to remediate myself. They gave me another opportunity but placed me on a Letter of Deficiency. My next rotation was going to be ICU but they switched it and made me do floors again. Obviously, I was placed under direct supervision. This block was terrifying for me, I was so nervous and anxious all the time, getting in there very early in the morning, chief residents were instructed to be present in my rounds to check on my presentations and thought process, I was barely sleeping or living, I was exhausted and I was also feeling very depressed since I was not allowed to cross-cover during this block. Long story short, the block ended, I progressed from direct to indirect supervision and was ready to move on to my next block (the one I was looking forward): research. However, I was called again by my PD; this time he pointed out that I didn't make enough progress to satisfy the LOD, there were still some concerns for me not promptly reacting to urgent situations (I was faulted because I texted my resident instead of calling her when I identified a patient with hypotension, I gave her fluids and got nurses involved as I was waiting for a reply from him/her but apparently I should have called, I was also faulted because we had a patient with hypoxemia that was in the low 90s when I saw him but otherwise stable, the attending, my resident and me started rounds on a different patient, when we got to this patient they reprimended me for not speaking out and dragging the team to round on this patient first) so they decided to extend the letter for 2 more rotations. By that time I was exhausted, I did 4 floor blocks in a row and I was going to do 2 more! I brought that up and they told me I could do an elective the first month and then floors again. So I did, I was working really hard during my cardiology elective, got really nice evals from the attendings, the only thing one of the electrophysiologists pointed out was that I needed to learn more EKG (which I totally agree with, EKG is not one of my strengths so I bought a book and everything to keep up with that). Last block: floors at the hospital where I began my intenship, this time I super familiar with the system, some of the nurses remembered me and we had a good relationship, I also had really nice residents and everything was going well, I was dedicated to reading about my patients every day, I was putting a lot of effort on my notes (which I was told they were really good) until my week of nights in which one day I was cross-covering and again, got paged for a patient with hypotension, I went to evaluate the patient, check the blood pressure myself, confirmed that she was 70/50, gave her a small bolus (small because she was an ESRD patient) and ask the nurse to page me back, didn't hear from her at all until I got an overhead page (for some reason the text-page didn't go throug), called her back and she told me BP was the same, I immediately contacted my resident and let him know about the situation, we checked the chart, order some labs and ended up transfusing the patient. Next morning I was paranoid, I checked the chart and saw an attending note that the patient improved with fluids and transfusion and discharge was planned for the following day. I felt relieved but again I was called by one of the chiefs, they were concerned about my management, I was told that I should have had my resident involved as soon as I was paged for a patient with hypotension. They told me I am not my own practice and what if, what if, what if, what if this patient crashed. My rotation ended without any other issues. I was called again to my PDs office to talk and I received a letter of dismissal. I was despondent to hear the news, but deep inside me, I knew this was a real possibility. I am lost, feeling that my career is over. My PD explained that the CCC feels they have given me the opportunity to remediate myself and that "the decision was made in light of the tremendous efforts required to produce minimal improvement". Some of the deficiencies outlined in the letter are repetitive like: "reacts appropriately and initiates management in common urgent/emergent situations: not achieved", but some others were new like "complete assigned educational and administrative tasks: not achieved" this meaning that I am not uptodate with submitting my clinical hours or completing blackboard cases (and it is a fact that I was not uptodate but talking to my peers nobody is!). I have requested all my evaluations with the final stats and I score a little bit below the 50th percentile in some competencies and a little bit above 50th in others.
Finally, to complicate the situation, I am a J1 visa holder and this visa is subject to the 2 year restriction, meaning that if I get terminated or resign, I have to go back IMMEDIATELY to my country (yes, 24hrs) and I am not able to apply to a work visa J1/H1 after 2 years of being terminated which means basically that even if I apply to the match this year, I wouldn't be able to start on July 2019.
At this point, I am in the middle of an appeal process, my question would be if this community believes there could be a possibility of reversal. I am also considering the possibility of transferring to a different program (a smaller program perhaps) but haven't found any open spots available as of today. Finally I talked to my PD about the possibility of extension of training (being as deficient as they are telling me I am, I am willing to extend my internship for 3, 6, 9 months if necessary) however they have told me they don't think that could be a possibility because as educators "they are not sure if the gap is going to ever close". I am going through the appeal process very discouraged, however, I also want to explore the possibility of repeating internship year, how common is that? Maybe people with more experience here are able to give me a word or two.
I apologize for the very long post, I really appreciate the people who take the time to read and post a comment.
