IMG PGY-1 Terminated from residency - SERIOUS HELP NEEDED

[Crayola227]

You can get away with doing a lot of things during residency but when the magic words of "patient safety" are invoked you must tread extremely carefully as that's your first step out of the door. The first question really was, where was the resident in all of this? If you had an excellent resident was s/he contacted when you felt the patient was difficult to manage? If, after the dust settles the answer from other people was "Dr. Hopes didn't contact us until after things had gone down" that brings your clinical judgment into question and now it involves a patient safety issue.

For example:

Resident: My intern called me on this combative delirious patient who could not be redirected. She had no EKG because no one could get EKG leads on her even after we treated her hypoglycemia and therefore we avoided giving haldol. So we gave a lower dose of olanzapine first, the patient was still flailing so we gave her some more for a total of 10mg because we were concerned she was going to hurt herself and staff. Subsequently she became obtunded and required a rapid response and transfer to the ICU.
Attending: My team had to address a violent delirious individual who could not be redirected and required chemical restraints and due to her other active medical issues deteriorated and required transfer to the ICU. Both the intern and resident were involved with the case for several hours and despite our best efforts she required enough medication she became obtunded and required transfer to a higher level of care.

Not:
Intern: I looked up olanzapine, saw that the starting dose was 10mg, didn't read any further about potentially giving a lower dose in "when clinical factors warrant" (actual Uptodate phrasing) and gave it because it was a really busy night and I was behind and didn't want to bother my resident.

The bolded.

Although, unfortunately, whether or not you get the first spin from the resident or not.... can depend on a number of factors.

I've had seniors you practically had to BEG and cajole into helping or seeing your quite ill patient. You hope this doesn't happen.
It's true that the best intern armor is deflecting too much responsibility by kicking things up the chain. It's saved my ass. I've had times I had to go above the senior to the attending. It's something you really, really, don't want to do, but you can't let your patient sink with you in the boat too.

"But the senior/attending told me to" is a really good response early on, unless it's something so stupid even an intern should know it is not a good idea to follow through on.

Paging or texting is not adequate alone. Pages vs texts - one is hospital approved and expected that officers will have on. Personal cell phones, not so much.

I would page, because that actually creates a record of something your senior is responsible for seeing, however, if that gets no timely response, you should page again, and in anything serious you page AND call. Because again, one creates a record, and one is a more direct method of trying to track them down. Be sure your page makes the situation clear as being serious and send more than one to explain if you must. Send an overhead page if you can.

If you can leave the patient, go physically track down your senior or attending if you must, if you can reasonably find them. Send a nurse if you can't leave bedside.

If you have to, and I've done this, approach any attending that might reasonably offer assistance. I've grabbed a hospitalist that wasn't on the teaching service when it seemed like help just wasn't coming or wasn't coming fast enough.

In the scenario with dosing, I've also ran something like that by anyone senior to me that could help - another senior in the room, an attending sitting next to me even if they weren't on my service. People expect interns to reach for a lifeline wherever they can get it. If it's not appropriate typically they'll help you find someone who should be helping you (assuming you tried already). It might be an annoyance but we all know that interns have to kick things up.

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[Crayola227]

Reading about this scenario, I really wonder if this was more of a straw broke the camel's back type thing, or that given reasons they wanted you gone this was a moment to highlight to justify it.

When I discuss a drug like this in a scenario like this with an attending, and I don't know dosage for a patient that doesn't seem terribly sturdy, once the attending says, "sure, give olanzapine," I'm asking, "OK, is there a dose you prefer?" Some won't know off the top of their heads, and some might roll their eyes because you can look it up and should know how to do so. Better to ask.

Also, in elderly, you ALWAYS have to be cautious about centrally acting meds. For such meds, I don't know that I would ever give the full UTD dose. Better less and then add more when you're just trying to hit the sweet spot of enough sedation to cool down hyperactive delirium but not obtund the patient. Keeping in mind such meds are actually deliorgenic (I've written elsewhere on this).

This is all hindsight, but hopefully any one coming up in training can read this thread and rather than just fear, learn something. It's never too early to learn this stuff.

 

[SilverCat]

Probably a stupid question, but how much of these emergency scenarios should a new intern handle on their own? I feel very incompetent--and in all of these scenarios OP mentioned wouldn't know what to do. I'm doing both an EM rotation now and am doing somewhat poorly--i.e.--completely missing obvious things that I shouldn't. I'll be doing a MICU rotation before intern year as well, but is there anything else to do if we're worried we'll be the incompetent resident? Just have a feeling of dread reading this story and don't know what to do.

 

[siliso]

And most seem to be FMGs because trouble adjusting to a totally new system and fixing the problem would take way too long. The rare AMG that does get fired is because of either a HUGE fk-up or actual violations like drug abuse.

In my experience it’s more often that a person has hit their ceiling of ability to adapt to expectations. Often people who have been on the grind with extraordinary effort even to get to residency and have maxed out their capacity when the line speeds up once again. And it’s heartbreaking and we do everything to help them succeed or help them get into a situation where they’ll be able to succeed. People with character problems who do a huge professionalism violation (like didn’t actually graduate med school but managed to get a training license on a preliminary transcript and thought it could slide under the radar) not so heartbreaking.

 

[siliso]

If you’re an intern then assess the situation and make a plan and then get it co-signed by your supervisor before taking irreversible action.

 

[Psai]

Probably a stupid question, but how much of these emergency scenarios should a new intern handle on their own? I feel very incompetent--and in all of these scenarios OP mentioned wouldn't know what to do. I'm doing both an EM rotation now and am doing somewhat poorly--i.e.--completely missing obvious things that I shouldn't. I'll be doing a MICU rotation before intern year as well, but is there anything else to do if we're worried we'll be the incompetent resident? Just have a feeling of dread reading this story and don't know what to do.

You're not expected to know everything or even anything. Always keep your senior in the loop, especially if you have a single doubt.

 

[siliso]

You are incompetent to practice independently as an intern, and that is expected and okay. What’s important is to recognize your limitations and seek supervision. Take ownership and make a plan but get it verified - then execute.

 

[CDI]

What the...this post scared the crap out of me and I'm just about finished with residency. Bout to open up a damn book and teach myself!

The fact that OP is actually a coherent IMG and at least gives off the impression as being genuinely understanding of their own mistakes (without blaming others) worries me even more.

Clearly a malignant program with some kind of odd agenda. I feel for OP. Trying hard but the man trying to hold em back.

This also gave me flashbacks about having a tough time as an intern. Both getting into residency and then as an intern with no clinical US experience aside from research. The one clinical "error" I've made in 3 years was on my first month on floors, I had a rapid called on patient cause of narcs beings given to close to each other. Patient was awake and reading a book, but was running soft on scheduled vitals check and the nurse bugged out. Since then I became a narc Nazi.

Advice to future interns: Bug your upper levels early on in residency (rather than later). You're an intern, and expected to not know squat. I bugged mine for every bit of knowledge I could get until I was comfortable doing stuff on my own. They might get annoyed but if they're a good upper level, they'll realize why you're asking.

Board scores don't mean much aside from filtering to get into residency. Once in, all bets are off.

I got 50-60 points less than our top scoring IMG on literally all the USMLE exams. Yet, just 3 days into our first floor block as interns, he turned in his badge to the PD cause he was so stressed out.

Except maybe for rocket science...EQ >>> IQ

And for OP, do whatever you gotta do to stay in your program. Once you're out there with a dismissal as an IMG, no one will ever look in your direction again. Sad part is, as an upper level, I bet you would have done a damn good job.

 

[NeurologyHopeful2018]

What the...this post scared the crap out of me and I'm just about finished with residency. Bout to open up a damn book and teach myself!

The fact that OP is actually a coherent IMG and at least gives off the impression as being genuinely understanding of their own mistakes (without blaming others) worries me even more.

Clearly a malignant program with some kind of odd agenda. I feel for OP. Trying hard but the man trying to hold em back.

This also gave me flashbacks about having a tough time as an intern. Both getting into residency and then as an intern with no clinical US experience aside from research. The one clinical "error" I've made in 3 years was on my first month on floors, I had a rapid called on patient cause of narcs beings given to close to each other. Patient was awake and reading a book, but was running soft on scheduled vitals check and the nurse bugged out. Since then I became a narc Nazi.

Advice to future interns: Bug your upper levels early on in residency (rather than later). You're an intern, and expected to not know squat. I bugged mine for every bit of knowledge I could get until I was comfortable doing stuff on my own. They might get annoyed but if they're a good upper level, they'll realize why you're asking.

Board scores don't mean much aside from filtering to get into residency. Once in, all bets are off.

I got 50-60 points less than our top scoring IMG on literally all the USMLE exams. Yet, just 3 days into our first floor block as interns, he turned in his badge to the PD cause he was so stressed out.

Except maybe for rocket science...EQ >>> IQ

And for OP, do whatever you gotta do to stay in your program. Once you're out there with a dismissal as an IMG, no one will ever look in your direction again. Sad part is, as an upper level, I bet you would have done a damn good job.

An IMG quit after just 3 days on the floor?

At my home program which is semi-malignant - the interns carry no more than 2 patients for first week!

 

[Raryn]

An IMG quit after just 3 days on the floor?

At my home program which is semi-malignant - the interns carry no more than 2 patients for first week!

At the program where I trained, you walked in to the same load you'd be expected to carry depending on where your team was in the call schedule.

I had 8 patients my first day. Some people had the full 10 associated with a post-call day.

Lets just say that when it came to logging duty hours the first month... we were... flexible...

 

[CDI]

An IMG quit after just 3 days on the floor?

At my home program which is semi-malignant - the interns carry no more than 2 patients for first week!

Yep. Third day on the floors he turned in his badge.
PD gave him 3 days off to get his ish together.
Came back and did okay after that but continued to have occasional trouble when the admits got hectic.
Consistently went way over duty hour limits to get work done.

Two patients for the first week probably makes the most sense. We had no such thing unfortunately - Day 1, "Here are your 10 patients, good luck and God bless!".

 

[PlutoBoy]

like didn’t actually graduate med school but managed to get a training license on a preliminary transcript and thought it could slide under the radar not so heartbreaking.

This actually happens?!

 

[NeurologyHopeful2018]

Yep. Third day on the floors he turned in his badge.
PD gave him 3 days off to get his ish together.
Came back and did okay after that but continued to have occasional trouble when the admits got hectic.
Consistently went way over duty hour limits to get work done.

Two patients for the first week probably makes the most sense. We had no such thing unfortunately - Day 1, "Here are your 10 patients, good luck and God bless!".

Is your program malignant? Your program is suppose to be care about "resident wellness" and provide as much support as humanly possible to help the residents succeed. It is a major RED FLAG on the program when a resident is not able to successfully complete the program - let alone walk out after a few days.

 

[Perrotfish]

Is your program malignant? Your program is suppose to be care about "resident wellness" and provide as much support as humanly possible to help the residents succeed. It is a major RED FLAG on the program when a resident is not able to successfully complete the program - let alone walk out after a few days.

If someone walks out after 3 months the program may be malignant. If they walk out after 3 days it's on them

 

[Doctor Christmas]

At the program where I trained, you walked in to the same load you'd be expected to carry depending on where your team was in the call schedule.

I had 8 patients my first day. Some people had the full 10 associated with a post-call day.

Lets just say that when it came to logging duty hours the first month... we were... flexible...

Me too! I started post call day, and had 9 brand new patients. It was not a fun day.

 

[FutureInternist]

Every intern should have this


https://play.google.com/store/books...gclsrc=aw.ds&dclid=CJbCseeurNoCFUuOaQodBKMNUw

 

[CDI]

Is your program malignant? Your program is suppose to be care about "resident wellness" and provide as much support as humanly possible to help the residents succeed. It is a major RED FLAG on the program when a resident is not able to successfully complete the program - let alone walk out after a few days.

No. That's called residency. Welcome to the real world...

 

[Siggy]

Probably a stupid question, but how much of these emergency scenarios should a new intern handle on their own?

None.
There are two answers that are always right and should be your default until you get your footing.

1. "Give me a minute and I'll come see the patient" (and go see the patient)

2. "Give me a second and let me check with my senior resident."

 

[evilbooyaa]

An IMG quit after just 3 days on the floor?

At my home program which is semi-malignant - the interns carry no more than 2 patients for first week!

Semi-malignant, no more than 2 patients in the first week? Sounds like they're being coddled.

 

[ThoracicGuy]

Semi-malignant, no more than 2 patients in the first week? Sounds like they're being coddled.

My first rotation on my intern year we had around 40 patients on the census at the pediatric hospital... There were no caps.

 

[FutureInternist]

Semi-malignant, no more than 2 patients in the first week? Sounds like they're being coddled.

It probably has to do with the logistics of a new computer system, figuring out which specialty team is on call, not knowing your way around the hospital etc.

Not seeing 8-10 pts for the first few days will in NO way hinder anyone’s training but will give them time to get their bearings and start on likely the most intense part of their life, in a good way.

At my program, the senior routinely saw 10-12 of our 14 pts on first day, and then give some of their pts to the intern on the 2nd day while they saw the new ones from overnight.

By day 4-5, interns know where everything is, which printers work etc and then the workload go up to 10-12 for them.

 

[Justanotherresident18]

OK, I just had to respond to this thread, not to communicate with OP, but to re-assure the other soon to be PGY1s who are understandably nervous reading this.

Lets just say, I might know who he or she who wrote this post is. To re-assure everyone.. this might be a large university program, interns leaving are generally unheard of, as there is a massive amount of support from both senior residents and the administration.

I'm not going to respond to OP directly, because he or she might be in an appeals process, and I don't want to completely call them out. Suffice to say, there is (understandably) a LOT they left out of the initial post.

OK, interns, here's how not to be fired from a first year internship, These may be things that the OP struggled with:

-Have a sense of urgency when returning pages or calls from nurses, midlevels, or other physicians. Take ownership of your patients, and never let it LOOK like you just don't care. Even if you have some degree of confidence that "sure a little fluid bolus for this hypotensive patient will be enough, I wont bother my resident with a call, I'll just text..." - NOPE -you're a PGY1, your goal isn't to show everyone you were a great physician you were in your home country, your goal is to show you can gather information, know when it is urgent, show you can work as part of a larger team, and communicate said information in an appropriate manner. If you have ANY concern, reach out to your senior resident, or your attending. Let the nurse on the other end KNOW you are doing this. Make an effort to show ownership of the situation, and see it through.

-Be respectful to nurses both on the phone and in person. I don't care how in your home country doctors are the be-all end-all. You have to know that in the USA, in US hospitals, nurses are valuable members of the team, and need to be kept in the loop. For the love of god, when you call them back be mindful of how you sound. Yes it may be a potassium of 3.4 at 2am... but if the nurse can audibly hear you rolling your eyes on the other end of the phone, your chiefs or attendings WILL be getting a call from the nurse manager. If this happens repeatedly, you are in rough shape.

-Be open to feedback. When an attending or resident is telling you how to improve (In any way), you may think you are being sincere by going "yea yea yea, ok ok ok", but it doesnt come off that way. Use closed loop communication - tell your attending, "That makes sense. I see why doing XXX was wrong, I'll try to do YYY in the future, thank you".

-Be mindful of being in the moment. What you do when you think no one is watching (ie, checking social media on your phone, in clear view of an entire room during morning report) is unprofessional and disrespectful to everyone's time. The way you dress, the way you interact with family members, the way you carry yourself on rounds... there is SO MUCH non-verbal, non-medical-knowhow behavior that affects how people see you.

-Finally, be aware of when you're being evaluated. If the uppers let you know there is a concern and you are being carefully watched by the program, you need to do your best to show that WHATEVER it is they are critiquing you on, is improving. Once again, critiques might be character or personality based-- these are just as valid as critiques based on lack of medical knowledge. Hell, I'd rather have an intern who has deficient medical knowledge over deficiencies in work ethic or character flaws/behaviors.

You really only get one or two first impressions, early on in intern year. Like it or not, that will set the course for how you're perceived, and negatives are hard and slow to fix. You WILL NOT get along with everyone in your program or hospital sites. Doesn't matter. You may have a resident who says something mean... don't get into a fight with them, smile and say thank you and move on.

If you guys start intern year as eager to work, eager to take feedback, eager to be part of an entire hospital-wide team, and eager to take ownership of your patients, you will be fine. Do not be afraid of this post.

 

[BigRedBeta]

Once again, critiques might be character or personality based-- these are just as valid as critiques based on lack of medical knowledge. Hell, I'd rather have an intern who has deficient medical knowledge over deficiencies in work ethic or character flaws/behaviors.

Absolutely agree with the bolded part - whenever I was supervising trainees, be they medical students when I was an intern, interns when I was a senior, or upper level residents as a fellow, I could absolutely make a difference with deficient medical knowledge. It's a lot harder to change character or behaviors (like inefficiency) and often times impossible to fix a terrible work ethic (usually because the person things they are working as hard as they can, or doesn't care enough to give any more effort).

 

[Kissmyabjj]

Damn...

OK, I just had to respond to this thread, not to communicate with OP, but to re-assure the other soon to be PGY1s who are understandably nervous reading this.

Lets just say, I might know who he or she who wrote this post is. To re-assure everyone.. this might be a large university program, interns leaving are generally unheard of, as there is a massive amount of support from both senior residents and the administration.

I'm not going to respond to OP directly, because he or she might be in an appeals process, and I don't want to completely call them out. Suffice to say, there is (understandably) a LOT they left out of the initial post.

OK, interns, here's how not to be fired from a first year internship, These may be things that the OP struggled with:

-Have a sense of urgency when returning pages or calls from nurses, midlevels, or other physicians. Take ownership of your patients, and never let it LOOK like you just don't care. Even if you have some degree of confidence that "sure a little fluid bolus for this hypotensive patient will be enough, I wont bother my resident with a call, I'll just text..." - NOPE -you're a PGY1, your goal isn't to show everyone you were a great physician you were in your home country, your goal is to show you can gather information, know when it is urgent, show you can work as part of a larger team, and communicate said information in an appropriate manner. If you have ANY concern, reach out to your senior resident, or your attending. Let the nurse on the other end KNOW you are doing this. Make an effort to show ownership of the situation, and see it through.

-Be respectful to nurses both on the phone and in person. I don't care how in your home country doctors are the be-all end-all. You have to know that in the USA, in US hospitals, nurses are valuable members of the team, and need to be kept in the loop. For the love of god, when you call them back be mindful of how you sound. Yes it may be a potassium of 3.4 at 2am... but if the nurse can audibly hear you rolling your eyes on the other end of the phone, your chiefs or attendings WILL be getting a call from the nurse manager. If this happens repeatedly, you are in rough shape.

-Be open to feedback. When an attending or resident is telling you how to improve (In any way), you may think you are being sincere by going "yea yea yea, ok ok ok", but it doesnt come off that way. Use closed loop communication - tell your attending, "That makes sense. I see why doing XXX was wrong, I'll try to do YYY in the future, thank you".

-Be mindful of being in the moment. What you do when you think no one is watching (ie, checking social media on your phone, in clear view of an entire room during morning report) is unprofessional and disrespectful to everyone's time. The way you dress, the way you interact with family members, the way you carry yourself on rounds... there is SO MUCH non-verbal, non-medical-knowhow behavior that affects how people see you.

-Finally, be aware of when you're being evaluated. If the uppers let you know there is a concern and you are being carefully watched by the program, you need to do your best to show that WHATEVER it is they are critiquing you on, is improving. Once again, critiques might be character or personality based-- these are just as valid as critiques based on lack of medical knowledge. Hell, I'd rather have an intern who has deficient medical knowledge over deficiencies in work ethic or character flaws/behaviors.

You really only get one or two first impressions, early on in intern year. Like it or not, that will set the course for how you're perceived, and negatives are hard and slow to fix. You WILL NOT get along with everyone in your program or hospital sites. Doesn't matter. You may have a resident who says something mean... don't get into a fight with them, smile and say thank you and move on.

If you guys start intern year as eager to work, eager to take feedback, eager to be part of an entire hospital-wide team, and eager to take ownership of your patients, you will be fine. Do not be afraid of this post.

 

[Mig2018]

Could you please update us!
Your story is too familiar. The exact thing that happened for me! I resigned and they told me it will be a clear resign! But actually it was not! I talked with lawyer, but it was too late to talk with a lawyer! I had already resigned!
They just report my mistakes! No body told me what was wrong and no body try to correct me when they saw that I was doing wrong!

 

[Crayola227]

Yep, never sign things re: your career with a medical board, hospital, physician's group/clinic, or a training program without consulting an attorney whose purview might include the document at hand.

In my own life, I have never regretted the times I consulted a reputable attorney, and God knows they are not cheap. OTOH, I regret more the times I should have gotten one, and didn't.

 

[Make Or Break]

Wanted to drop a couple thoughts here for other soon-to-be interns who are reading this story with dread. OP, I do hope you are able to find a workable path forward. Your attitude is such that I think anyone reading wants to see you succeed. It sounds like you and your program have both acted in good faith and I hope your PD will help you as you look for your next position. The visa issues are not my forte, but I have seen hospitals create temporary positions to help people like you bridge the gap.

Ok so takeaway points for future terns, with credit to countless seniors who said all these things to me:

1) Foolproof algorithm for managing ALL issues as an intern-
A) see the patient (no call room medicine)
B) call your senior
C) do what you’re told

2) nobody cares about your knowledge base. They care about what you can get done. This year is about doing what you’re told, not as much about thinking. The thinking and learning happens, but the crux of your role is executing the plan that’s been given to you.

3) if at any time you feel yourself starting to have an independent thought, call your senior immediately. They will help you through this difficult time.

4) October 1st is a far more dangerous time in the hospital than July 1st. This is when interns start to feel a little more comfortable but shouldn’t be. Keep calling, keep doing what you’re told. Note that this pattern will continue even for your seniors and fellows. There’s nobody more confident than someone 3-6months into their new role. They just haven’t been burned yet. As a tern, you protect yourself and your patients by running things up the chain.

5) always be rounding. Good interns check in on their patients and always have a finger on the pulse of the service. Patients rarely crash suddenly and if you’re always seeing them you’ll often see the signs of impending doom long before nursing pages you about plunging vitals. With EMRs, people don’t rely on you for the numbers as much because we can all see those as they result; they do rely on you to be seeing your patients and examining them frequently, especially anyone with active issues.

6) always call. Don’t rely on a text. We all know the little ding doesn’t always wake you up. Call. Call again. If your senior doesn’t want calls about urgent issues, then that’s a major problem and maybe they need to find a new line of work.

7) try to imagine what you would want to say in front of your whole faculty at M&M if things go bad. Notice what gets said or asked EVERY time: when was the senior notified? When was the attending notified? Do you want to stand in front of a dept and say you saw the unstable patient and texted your senior? The s—t roles downhill, but the blame rolls up. Once major decisions have been run up the chain, nobody will be looking to you to justify the decisions. Sometimes badness happens regardless and we do have to practice defensive medicine. Defensive medicine for an intern involves seeing patients promptly and running all issues up the chain.

Don’t overthink intern year. See, call, do.

Thanks a ton for this. I havent even started intern year yet and was already freaking out after reading OP's post. You da best.

 

[doctorKAT]

Just wondering what can the OP's former PD do to help the the OP in looking for another position?

 

[NotAProgDirector]

They can give them a fair summary of their strengths and weaknesses, and can forward any notices of open PGY-1 positions.

 

[firstaidhelp]

Check out
Dysfunctional Programs - The Graduate Medical Education Compliance Project (GMECP)

 

[ThoracicGuy]

Check out
Dysfunctional Programs

Is this an ad?

 

[gutonc]

Is this an ad?

More of a rant.

 

[ThoracicGuy]

More of a rant.

I thought it was more the guy was advertising his own site/blog/rant/whatever.

 

[gutonc]

I thought it was more the guy was advertising his own site/blog/rant/whatever.

I think we banned the account that was spamming that site awhile ago.

The site is a whole bunch of crazy, but it's non-commercial.

 

[Crayola227]

I like the site, it makes some decent points and has some links to more reputable papers/sources. Some of the advice for struggling residents is valid in my opinion.