Imminent termination, need serious advice!!!

[MDesquire]

you are exhausting mdesquire...you will do better when you play better with others

I've had my share of situations fall apart in life, that trend drastically changed when I realized I was the common denominator and worked on changing me. I'm trying to react to you like you are teachable, although you are acting like you want to be in the shunning category.

Thank you for sharing sb247. There is a very humanizing quality to your comments. It sounds to me like you are claiming that I can't handle the truth, when all along I've just wanted to go to bat for the OP.

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[deleted480308]

Thank you for sharing sb247. There is a very humanizing quality to your comments. It sounds to me like you are claiming that I can't handle the truth, when all along I've just wanted to go to bat for the OP.

if you have great intentions when you advise me to jump off a cliff, I still go splat

your advice and approach is wrong, I'm not doubting your intentions

 

[Law2Doc]

Thanks for the Swayze comparison, I'll take it, however I hardly see myself as an outlaw in this scenario....

"It's over Johnny " is a quote from Rambo... The whole guns blazing approach to negotiations...

 

[medstudent115]

how likely is that person who is going through all this will suffer from Adjustment Disorder with anxiety or depressive symptoms? that will affect johndoe44's life and work performance.

 

[MDesquire]

That's not a conspiracy theory, that's politics. If you can't legislate the change you want, you find an alternative plan to lead you to the same endpoint.
And your advice, unless I misread it, was to leave quietly and have your attorney become a thorn in the PDs side and negotiate on your behalf. A costly and unnecessary error, one that could immediately close the door on an amicable split. When your attorney starts talking to the PD, the Hospital's and/or University's attorney takes the wheel and the focus changes from amicable agreement to protection from liability, and the University attorney doesn't care at all what happens to some dismissed resident with a history of bad evaluations. In fact they would almost certainly advise the PD to NOT write a vague or even neutral LOR because it could be used in the presumed forthcoming lawsuit to prove you were in fact terminated without cause and entitled to significant damages. I'm not sure why you don't see that.

No ether man, my advice was to secure a neutral at worse PD eval, and walk away quietly. If it took an attorneys intervention to accomplish that goal, and that meant the risk of an escalation, IMO thats one the OP must take to secure his chances of procuring an alternate carrier. That decision would have to based on credible evidence that OPs termination was brought in bad faith or without substance. If cause is well substantiated, the OP is up a proverbial creek without a paddle.

The OP should never become confrontational with anyone if he has the means to hire counsel. As it stands now the PD has agreed to narrowly tailor his speech 'aka' that which is no greater than necessary. The amicable split as it appears now will be based entirely on conditions subsequent that are predicated on good faith assurances and nothing more. Are there inherent risks to that situation that have not yet been addressed here? You bet there are. However, in the interest of the OP and as a matter of sensitivity I don't see the merits of expounding upon them. Its too early to draw any conclusions at this point IMHO. Glad to see your making good faith attempts to get yourself caught up. Keep going.

 

[BlondeDocteur]

@johndoe44 I think it will help multiple people who will undoubtedly be in a similar situation one day to know how you & your PD are going to discuss your resignation, both in his letter and in your interviews. What are you going to say that is both honest and positive?

Also, I think it will help your case in future residency applications to demonstrate some kind of plan where you're working on your deficiencies. Perhaps ask for help constructing a good, solid reading program. Perhaps attend CME seminars (that's definitive proof you've done something to remediate a poor fund of knowledge)-- I know they can be pricey but they might have discounts for trainees? Attend big meetings/conferences in your field of interest, both to hobnob and to get the CME credits.

You might also shotgun out applications to non-competitive IM programs for a PGY-2 spot (succinctly email the PD with a copy of your resume and step scores). There are certainly unadvertised spots, and if someone resigns, is fired, etc from one of these programs they might reach out to you.

 

[MDesquire]

if you have great intentions when you advise me to jump off a cliff, I still go splat

your advice and approach is wrong, I'm not doubting your intentions

Not if you've got a golden parachute sb247. Feel free to put some skin in the game and ratify some advice. So far you've been quick to take a seat next to Statler and Waldorf, all the while noticeably devoid of pragmatic suggestions.

 

[deleted480308]

Not if you've got a golden parachute sb247. Feel free to put some skin in the game and ratify some advice. So far you've been quick to take a seat next to Statler and Waldorf, all the while noticeably devoid of pragmatic suggestions.

I'm washing my hands of you. Good luck

 

[Attending1]

You've received a bunch of good advice on this thread.

It is common for interns to start to struggle the last 3 months of the year. This is the time when we want them to be taking charge, developing plans, demonstrating that they can work with indirect supervision. So it's not completely surprising to me that you could have good performance for 8-9 months, and then start to get poor evaluations.

The difficult thing with trying to give you advice is that honestly, I don't know what the problem is. One possibility is that your clinical skills are just fine, and you've been railroaded by a corrupt system. Perhaps you pissed someone off. Or maybe they just pick people to pick on. But in this scenario, you are fine and are getting screwed by your program. That's one option.

The other possibility is that your clinical skills are far behind your peers. In this case, your insight (which you state is fine) is actually not good. Which is not an uncommon problem -- as you can imagine, residents with poor clinical skills and poor insight always blame someone else for their problems. In this case, the problem is you, and you can't see it.

In reality, this is a spectrum -- and you fall somewhere along it. And I can't tell where.

But I'm concerned that your insight isn't as good as you think it is. For example, in your PGY-1 you were pulled into your PD's office and told that your performance on ICU and other rotations was concerning and there were concerns about patient safety. Let later you mention that you had no idea your job was in jeopardy. It is quite possibly true that your PD didn't say "If this doesn't get better, you will be fired", but I think most residents would recognize the seriousness of the situation. From your description, it sounds like you didn't really believe it / take it seriously, just "showed up 30 minutes earlier".

As an IMG who is failing out of a program, I think you also underestimate how difficult it will be to get another position. As has been mentioned on this thread, one thing that can be very helpful is a letter from your current PD supporting you for "another chance". Without that, you may find your options somewhat limited. I am assuming that you were planning on listing this training on your ERAS application. What exactly were you planning on listing for "Reason left?"

Hi guys,

Just happened to see this unfortunate thread on SDN. Residency contract non renewal/ getting fired from residency is a life changing event for a resident, and this topic needs to be discussed and debated much more - ethically and legally

I am an IMG who did an Internal medicine residency in India, worked as an Assistant Prof of IM in India, before moving to the US, and completing my IM residency in the US in flying colors. I have been practicing as an Attending Physician at a medical centre in Virginia for more than 10 yrs.

Now all of us, especially Attendings (those who have crossed the bridge) need to understand that residents are a very vulnerable group, and most of these residents being fired, even those deemed academically weak are very much salvageable. (I'm not talking about the resident fired for criminal behaviour)

These "resident incompetence" firings, in my opinion, are mostly because:

Many of Attendings and PDs, (especially at places where firing residents is commonplace) are shirking their job !

Let me explain: "Residency Training" - that's what it's called - is not a job, it is training;
Attendings are supposed to coach residents reg. focused history taking, clinical examination, eliciting signs, work up and management plans for patients - are they really doing these things sincerely? I found many of the Attendings known to be "tough", to actually be lazy bullies - who would want residents to be submissive labourers rather than treat them as "doctors in training". Most of the tough Attendings want to play "judge", but don't have the competence to play "teacher"! And, they are getting away with it.

If a resident, especially an intern, is terminated for academic incompetence, then it means that the Attendings/ PD/ program who recruited him just a year ago is incompetent in screening, interviewing and admitting residents. What penalty is the program going to pay for it's failure?

Secondly, there needs to be stringent and objective legal apparatus for evaluating the steps taken by the program to remediate the resident, before nonrenewal/ termination. Only after exhaustive and objective remedial exercise should a program be given authority to terminate a resident.

Failure in the ability to remediate should lead to enquiry reg. this failure by the board/ acgme, and a stringent punishment ex: loss of accreditation should be imposed if determined that the program made no concrete/ objective remedial exercise

Thirdly, the PD's letter should not be a "sword of Damocles" around a terminated resident's neck. The requirement for a previous PD's letter, when applying for a fresh PGY-1 position should be abolished; Even for a PGY 2 or 3 position, only the given credit should be mentioned

Of course, if a criminal act/ proven sexual misconduct is the cause of termination, then it must be mentioned in the PD letter/ communicated to the licensing board.

I must say, that I too felt very vulnerable to the whims and fancies of my Attendings/ senior residents during residency, - as have so many of you - and this is due to the gross imbalance of power between faculty and residents. I was thankful to my prior training on many an occasion, and felt that this helped me do some out-of-the-way extra work to please their whims. My IM residency training in India was very strong on the teaching front, despite lacking in facilities compared to the US. Residents there had guaranteed 3 yr terms - you can't be kicked out unless you indulge in criminal activities/ blaring medical negligence etc. - if you are an academically poor resident, you will fail to clear the exit examinations or will have to repeat the course over again - but you will at least not be kicked out based on hearsay. What i say, is that despite the US medical facilities being the best in the world, the US residency system is embroiled in hearsay medieval politics even compared to developing Asian countries.

That's the point - residents should not have to be virtual slaves trying to please their seniors and Attendings- they should be secure trainees with their minds focused on gaining medical experience.

It's not just terminated residents, but even faculty and PDs need to have insight into these complex aspects of resident termination

I hope that the senior Attendings in the SDN, especially people like APROGRAMDIRECTOR take note of my points, and strive to improve the pitiable working conditions of medical residents.

Look forward to comments

Thanks

 

[Gastrapathy]

Nearly every time I've seen a resident fired, the only thing that was remarkable was how long it took to get there. These threads are always from the side of the resident. Virtual slaves? Give me a break.


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[BlondeDocteur]

I can see both sides of the coin here. On the one hand, past performance as a student is not necessarily a good predictor of future performance as an employee. It usually is, but not always. And the jump from studenthood to genuine responsibility is a jump that most of us-- but definitely not all of us-- can make.

There are people who were perfectly adequate medical students who are very poor residents. It's one thing to have a skillset which revolves around reading, memorizing and taking exams, then around a very limited number of directed patient interactions where every single step of your 'management' is directed and double-checked by someone else. It's quite another to have a panel of patients, to be alone in a hospital at night, etc. And I think the reason so many people falter towards the end of internship is that so many of the skills that are prized early on in internship-- efficiency, multitasking, being pleasant and so forth-- don't carry you when you get to the stage where your genuine medical decision-making becomes important.

I personally know of four resident firings, all in surgery, from the inside. All were deserved, on the merits. One dragged out three years longer than it should have until the program was absolutely forced to let the resident go-- it was for completely unreliable & unprofessional conduct and extremely poor medical/surgical skills. One was due to an insufficient level of proficiency in English (fired mid-year). One was due to an inability to function in a harsh, hostile medical climate in addition to a dramatic personality mismatch (she lawyered up, is suing her hospital in federal court, and has thermonuclearly destroyed her US medical career as a result). And one was a friend from medical school who was an inefficient, slow, insecure resident but who was deeply dedicated to her job; she was fired ten months into internship. She spent a year trying to get back into medicine, found all the doors closed, and killed herself.

 

[rokshana]

Thanks for the Swayze comparison, I'll take it, however I hardly see myself as an outlaw in this scenario. I hope for the OPs sake, what you assert is true, but I think its still early to be feeling confident. My approach would be the same for both scenarios, and we can agree to disagree on this. Hopefully at the very least this thread has served its intended purpose of directing the OP to counsel and the importance of soliciting everything he can for documentary and self-improvement purposes. As an ancillary benefit it exposed some of issues that are brewing at the AMA/AMSA and State legislative level. There's a good quote by Osler that comes to mind, regarding your sentiment...

"He who knows not and knows not he knows not: he is a fool - shun him. He who knows not and knows he knows not: he is simple - teach him. He who knows and knows not he knows: he is asleep - wake him. He who knows and knows he knows: he is wise - follow him.”

Thank you for your good wishes.

don't really think that was the point of the thread….and the OP did NOT take that tack…so if that was the point for YOU…you failed.

 

[meerkat111]

The alarming thing is- there are some residents who feel that everyone has to forego all kinds of personal life and take psych medications, get divorced, abandon your children, whetever it takes to keep their spot. These forces do not help create a fair system in a residency. In other words, this type of residents fail to see that some programs infact do fire the residents unfairly. To them, they are the anointed who are chosen to become licensed docs and the rest should die or leave the profession. We, as residents are also responsible to support other residents and create some kind of resident support group to prevent abuse. I think in some ways, residents help propagate the vicious cycle of getting abused and then going on to abuse others once they become attendings.

 

[ThoracicGuy]

Not if you've got a golden parachute sb247. Feel free to put some skin in the game and ratify some advice. So far you've been quick to take a seat next to Statler and Waldorf, all the while noticeably devoid of pragmatic suggestions.

I'm just curious about a couple of things.

1. Have you graduated law school?
2. If not, are you currently in law school?
3. If so, have you passed the bar in any state?

 

[anes]

The alarming thing is- there are some residents who feel that everyone has to forego all kinds of personal life and take psych medications, get divorced, abandon your children, whetever it takes to keep their spot. These forces do not help create a fair system in a residency. In other words, this type of residents fail to see that some programs infact do fire the residents unfairly. To them, they are the anointed who are chosen to become licensed docs and the rest should die or leave the profession. We, as residents are also responsible to support other residents and create some kind of resident support group to prevent abuse. I think in some ways, residents help propagate the vicious cycle of getting abused and then going on to abuse others once they become attendings.

Residency is nothing more than indentured servitude. What you have to do is accept this fact and try to balance everything else. The only way to change anything would be for residents to unionize.

 

[Doctor Bagel]

And one was a friend from medical school who was an inefficient, slow, insecure resident but who was deeply dedicated to her job; she was fired ten months into internship. She spent a year trying to get back into medicine, found all the doors closed, and killed herself.

That's so tragic. Wow. Not to say you can blame the program entirely for her suicide, but you would think a program would try to help a conscientious resident like this out either by helping them get into another specialty or more relaxed program or help with remediation.

 

[Gastrapathy]

Residency is nothing more than indentured servitude. What you have to do is accept this fact and try to balance everything else. The only way to change anything would be for residents to unionize.

So...you didn't learn anything in residency?


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[medstudent115]

@ Attending1 I like your comments you have been precise and to the point in explaining how the US residencies are built up. 85 to 90 % of residents are selected on their merit. In such cases most of the times( contract non-renewals) the hardworking resident says if they had a timely feedback they could have improved. So they do they not hear from the evaluating attending until the damage is done. PD knows even before the resident knows what he/she knows ( as evaluating attending tells PD before taking any steps to tell the resident and help him/her for successful completion rotation). I seems some time that residents are there to help attending and not for getting trained. Different programs of same specialty through out the country are different in many many ways: their structure, teaching and training. US training lacks uniformity in training residents, one resident who is fired from one program may be better than the best resident in the other program. So point is that their should be clear cut rules for non-renewal of residents ( not hypothetical), weekly feedback to residents for their performance. I do not know much but I am sure wise people on this forum will have lot to say in this regard.

 

[drcrispmd]

Weekly feedback? That is a little much, unless the resident is on probation and trying to improve to keep from getting fired. If you want more feedback, ask your attendings but making all residents sit down for weekly feedback is a waste of time. That is what evaluations at end of rotation are for and if you want verbal feedback ask!

 

[anes]

So...you didn't learn anything in residency?


Sent from my iPhone 6 using Tapatalk

Of course I learned in residency. That doesn't mean that we weren't mistreated as residents. I went to a large univesity program where resident teaching should be their number 1 priority. However, we (residents) were always treated worse than any other group in the hospital.

Would a nurse tolerate being told to stay extra and not be paid for it? We were routinely told to lie about duty hours. We were routinely told that if we didn't lie about hours that the program would get shut down or patient care would suffer. One person complained that we were breaking hours all the time. They ended up being placed under increased scrutiny and placed on probation for "non professionalism". This person was a good resident with excellent in training scores.

What other group would tolerate this sort of behavior? We put up with it because of fear for our careers. The only other place where people have this much authority over your whole life/career is in the military. Again, what we go through is indentured servitude.

 

[AStark]

Weekly feedback? That is a little much, unless the resident is on probation and trying to improve to keep from getting fired. If you want more feedback, ask your attendings but making all residents sit down for weekly feedback is a waste of time. That is what evaluations at end of rotation are for and if you want verbal feedback ask!

I disagree. Certainly in programs like anesthesiology daily feedback is often the norm. On a recent ICU rotation we received staff feedback after every call shift, along with a sit-down mid-point evaluation and a similar one at the end. I think IM programs can be deficient in providing frequent, regular feedback, but that doesn't mean it shouldn't or can't happen. My preference is for daily feedback, but that's not necessarily practical outside the OR context where residents typically work one-on-one with staff for an entire day (or call shift).

 

[IlDestriero]

I try to find something done well and something that could be done better whenever possible and share that in a brief debrief at the end of the day with the res/fellows.
I think they like the feedback and it is reflected in superior teaching scores. If I remember suggesting the same thing for improvement more than once, if not trivial, I point that out as well. Ignoring constructive criticism is not a habit residents should have if they want to succeed. Every now and then we get a resident that within just a few days earns a reputation for being weak, and that is proven out time and time again. It is useful to share those observations with the other faculty that have to cover him/her, and we do. I always think how nice it is to be able to send them back after a month to go back to being someone else's problem. You can try to make them better physicians, but when they seem deficient in basic skills and knowledge, it makes me wonder how they made it this far.

 

[drcrispmd]

I could see why daily feedback could be useful in anes or surgery. For FM, no. Same with after call. I had many calls that the only time I would have contact with the attending would be am rounds (if no one was admitted, which I had a few calls that was the case). We are also in the clinic a lot so it would be a waste of time, unless the resident was struggling. We covered OB 24/7 in my hospital as well as peds and newborns. Those attending were giving informal feedback all the time. I think that kind of interaction is best instead of scheduled weekly feedback. New residents seem like they need to be told all the time they are doing a good job. Some are very defensive if given other feedback or suggestions on how they could have done something differently. We had end of rotation evals which were easily found on new innovations and we were encouraged to seek more verbal feedback if wanted. We had 2 or 3 360-evals done a year where we sat down and went through everything with an attending.

 

[Law2Doc]

I disagree. Certainly in programs like anesthesiology daily feedback is often the norm. On a recent ICU rotation we received staff feedback after every call shift, along with a sit-down mid-point evaluation and a similar one at the end. I think IM programs can be deficient in providing frequent, regular feedback, but that doesn't mean it shouldn't or can't happen. My preference is for daily feedback, but that's not necessarily practical outside the OR context where residents typically work one-on-one with staff for an entire day (or call shift).

Daily feedback would be AWFUL. It means you'd always be under the gun and the attending would always be looking for something concrete to say about you, often critical. It would mean s/he'd be able to let fewer things slide without mention. While I could see how this might perhaps be helpful for the 1% of residents who need to know real time that they are screwing up and why, it would be a living he'll for the other 99% of residents who actually have pretty good insight in what they are struggling with and would be happy to keep their heads down day to day and only get judged on an entire rotations body of work, rather than individual days. I personally think there's already too much feedback in the process -- I wouldn't have minded if the ACGME required the formality of sitting down with the PD once a year rather than twice. It's like looking at a piece of art -- as a whole it might be great, something you'd hang on the wall. But if you break it down by the mm, and look really close you can undoubtedly find blemishes. Sometimes less is more.

 

[dpmd]

I don't know about really frequent formal feedback but every day that the intern is lacking in some way is a day that his senior (and the staff if they are reporting diectly to staff) should say something. If an intern is always getting talked to that is a heads up that their performance is sub par. The problem is when the senior doesn't call attention to issues or if they are such dicks all the time that you can't tell the legitimate complaints from the nitpicking. I suppose another issue would be if the intern views legitimate complaints as just dickish nitpicking.

 

[oldbearprofessor]

Daily feedback in an ICU setting often means that during sign-out in the morning or evening, the attending BRIEFLY discusses some of the most important decisions the resident made (boluses, drips, etc) and gives some constructive suggestions. It is common in an ICU setting and many residents and fellows seek it out regarding difficult patients. Mid-point evaluations are mandatory for med students by LCME, and are highly recommended for residents/fellows by ACGME. They do not have to be laborious, simply a brief couple of comments to help guide the trainee.

With regards to some of the bigger issues in this thread and the similar ones, it is important to realize, as those of us who do critical care do, that some residents are just not good or comfortable with this environment. I've had lots of residents that all of us were glad they were done in the NICU who did a great job elsewhere and have become fine attendings in various areas of pediatrics. For the resident who is truly uncomfortable in the ICU type setting, the most important thing is to become an accurate source of information for those who are comfortable and skilled at decision making and to know when to ask for help. The only residents who really worry us are ones where I might ask "How much Lasix did you give last night?" and I'll get back "2 mg/kg". I'll ask "IV or PO?" and they'll answer "PO."

Then I look at the chart and the baby got 1 mg/kg IV that night. This type of thing is common and reflects both disorganization and some poor ability to understand when to say "I don't know, let me check" instead of making up an answer. This can be remediated but needs very intense faculty input. Generally, our goal is to get the person through the rotation and let non-critical care services evaluate them further, but some ICU type attendings will more aggressively deal with this situation.

 

[DermViser]

Daily feedback in an ICU setting often means that during sign-out in the morning or evening, the attending BRIEFLY discusses some of the most important decisions the resident made (boluses, drips, etc) and gives some constructive suggestions. It is common in an ICU setting and many residents and fellows seek it out regarding difficult patients. Mid-point evaluations are mandatory for med students by LCME, and are highly recommended for residents/fellows by ACGME. They do not have to be laborious, simply a brief couple of comments to help guide the trainee.

Is this a relatively new thing?

 

[oldbearprofessor]

Is this a relatively new thing?

I don't think it's very new but not really sure when started

https://view.officeapps.live.com/op...ww.lcme.org/publications/db_1314_section2.doc

see ED-31 as quoted below....

ED-31. Each medical student in a medical education program should be assessed and provided with formal feedback early enough during each required course or clerkship rotation to allow sufficient time for remediation.

Although a course or clerkship rotation that is short in duration (e.g., less than four weeks) may not have sufficient time to provide a structured formative assessment, it should provide alternate means (e.g., self-testing, teacher consultation) that will allow medical students to measure their progress in learning.

b. Describe the institutional policies and procedures that are in place to ensure that students receive formal feedback at the mid-point of a clerkship/clerkship rotation. Describe the means by which the occurrence of mid-clerkship rotation feedback is monitored within individual departments and at the curriculum management level.

 

[DermViser]

I personally know of four resident firings, all in surgery, from the inside. All were deserved, on the merits. One dragged out three years longer than it should have until the program was absolutely forced to let the resident go-- it was for completely unreliable & unprofessional conduct and extremely poor medical/surgical skills. One was due to an insufficient level of proficiency in English (fired mid-year). One was due to an inability to function in a harsh, hostile medical climate in addition to a dramatic personality mismatch (she lawyered up, is suing her hospital in federal court, and has thermonuclearly destroyed her US medical career as a result). And one was a friend from medical school who was an inefficient, slow, insecure resident but who was deeply dedicated to her job; she was fired ten months into internship. She spent a year trying to get back into medicine, found all the doors closed, and killed herself.

By harsh medical climate do you mean in Surgery (in general) or your particular program? I think the last case scenario is the most sad - just bc she wouldn't have made a good surgeon doesn't mean another field would not have been good for her - i.e. Radiology, Pathology, etc.

 

[oldbearprofessor]

If a resident, especially an intern, is terminated for academic incompetence, then it means that the Attendings/ PD/ program who recruited him just a year ago is incompetent in screening, interviewing and admitting residents.

I've read literally thousands of MSPE's and older dean's letters, LOR's, etc. Very very very few are forthcoming about disorganized residents or other major issues that they don't HAVE to tell us about (e.g. formal action). There is very little way to pick this up in a 30 minute interview either. When we have a highly problematic trainee we go back and look at these letters and are often amazed at what they say vs what we see. There are many reasons for this beyond the scope of this thread, but it is not correct that those who recruited a poorly performing trainee did not do their due diligence. Same applies all the way up the pipeline to Chairs and Deans.....

 

[Attending1]

"Feedback" and "constructive criticism" should be welcome things as long as they are part of "teaching". Instead most of the times "feedback" has become something that residents (especially the troubled ones) dread, because it is only becoming a part of "judgement", with the "teaching" part erased out.

 

[DermViser]

I've read literally thousands of MSPE's and older dean's letters, LOR's, etc. Very very very few are forthcoming about disorganized residents or other major issues that they don't HAVE to tell us about (e.g. formal action). There is very little way to pick this up in a 30 minute interview either. When we have a highly problematic trainee we go back and look at these letters and are often amazed at what they say vs what we see. There are many reasons for this beyond the scope of this thread, but it is not correct that those who recruited a poorly performing trainee did not do their due diligence. Same applies all the way up the pipeline to Chairs and Deans.....

What about the actual grade though? Honors vs. High Pass vs. Pass.

 

[oldbearprofessor]

What about the actual grade though? Honors vs. High Pass vs. Pass.

Uncommonly all that helpful from core rotations in identifying future residents/fellows who will have major problems. Sub-I's and detailed commentary from any rotation are more helpful, but still, a lot isn't said and we all are aware of the limits in how core rotations are structured in terms of learning whether someone is prepared to care for very sick patients.

 

[oldbearprofessor]

Instead most of the times "feedback" has become something that residents (especially the troubled ones) dread, because it is only becoming a part of "judgement", with the "teaching" part erased out.

If true that "most of the time" there is no teaching (I do not agree, but you are entitled to your opinion), then that is reason to improve how feedback is given, not decrease feedback. We train our faculty in how to give feedback, although of course it isn't always possible to directly observe.

 

[Arcan57]

The purpose of residency is to turn medical students into physicians capable of independent practice in that field. To the extent that someone is not capable of practicing independently then they should not be allowed to complete their residency. The safeguards in place after completing training are largely designed to catch egregious behavior (ie practicing while impaired, fraud, or boundary issues with patients). Especially for non-hospital associated physicians there are very few hard stops for simple incompetence. Any change in disciplinary process in residency has to balance the rights of the resident vs. the requirement to produce a practitioner that is not dangerous to their patients. I don't honestly know how you could turn that into a purely objective process without becoming so invasive as to actively impede training (think Joint Commission).

 

[Attending1]

If true that "most of the time" there is no teaching (I do not agree, but you are entitled to your opinion), then that is reason to improve how feedback is given, not decrease feedback. We train our faculty in how to give feedback, although of course it isn't always possible to directly observe.

Regular constructive feedback is a good thing, don't get me wrong.

What I say is that feedback on a day-to-day basis must mean to emphasise on teaching, correcting and improving residents, rather than just watching their inadequacies, and writing a bad review.

For instance, we know that comprehensive ventilatory management is not taught in medschool anywhere - How many of the IM/ Critical care/ ICU Attendings at your hospital actually sit down and explain "top to toe" or even the salient basics of vent management to junior residents?
I guess not many - WHY ? Because they don't need to care, as their teaching activity is not required to be monitored.

So say when an ICU attending, knowing well that vent management is not adequately taught in medschool, just gives a bad ICU evaluation (for incompetence in vent management) to an intern in his first/ second ICU rotation - is it justified ? ( without bothering to attempt teaching him) ?

And, we know that things like vent management need to be explained and demonstrated, you can't just learn it all by reading a book

Well, my point is that we need to be demanding on not just residents, but also on faculty ( make sure they teach, not just judge)

 

[oldbearprofessor]

How many of the IM/ Critical care/ ICU Attendings at your hospital actually sit down and explain "top to toe" or even the salient basics of vent management to junior residents?
I guess not many - WHY ? Because they don't need to care, as their teaching activity is not required to be monitored.

Well, I confess that since we're a children's hospital, not many IM attendings do much teaching. However, if you mean NICU and PICU, it is standard as a topic for our NICU and PICU attendings (and fellows) to cover ventilation types and strategies. As far as monitoring teaching, each resident and fellow submits an evaluation of the rotation and where there are major teaching deficiencies, we hear about them rapidly and correct them. Obviously, we don't record rounds every day and there is some variation in how teaching is done, but your criticism, at least in "my hospital" is just that, a non-evidence based criticism based on your opinion of how you think we teach. I have never heard of a resident being criticized for not knowing different ventilation strategies in the NICU before they were taught them. They MAY be criticized for making changes on the ventilator beyond their knowledge base, but that is an appropriate topic for the attending to "teach" about.

 

[Attending1]

Nearly every time I've seen a resident fired, the only thing that was remarkable was how long it took to get there. These threads are always from the side of the resident. Virtual slaves? Give me a break.


Sent from my iPhone 6 using Tapatalk

Well that's apathy

The residents are the vulnerable lot, career wise they lose EVERYthing if they get terminated - the programs lose nothing. So the threads need to give genuinely deserving residents some helpful advice.

And I prefer residency training to be a place where "the mind lives without fear" !

 

[Attending1]

Well, I confess that since we're a children's hospital, not many IM attendings do much teaching. However, if you mean NICU and PICU, it is standard as a topic for our NICU and PICU attendings (and fellows) to cover ventilation types and strategies. As far as monitoring teaching, each resident and fellow submits an evaluation of the rotation and where there are major teaching deficiencies, we hear about them rapidly and correct them. Obviously, we don't record rounds every day and there is some variation in how teaching is done, but your criticism, at least in "my hospital" is just that, a non-evidence based criticism based on your opinion of how you think we teach. I have never heard of a resident being criticized for not knowing different ventilation strategies in the NICU before they were taught them. They MAY be criticized for making changes on the ventilator beyond their knowledge base, but that is an appropriate topic for the attending to "teach" about.

Well, it seems that your hospital definitely has a better teaching system than most other places that I have seen, including my own, and I am glad about that !

 

[dozitgetchahi]

"Feedback" and "constructive criticism" should be welcome things as long as they are part of "teaching". Instead most of the times "feedback" has become something that residents (especially the troubled ones) dread, because it is only becoming a part of "judgement", with the "teaching" part erased out.

Yeah...see this is what bothers me about what residency training has turned into. Many, many programs out there (even 'good ones') seem to operate under a format that basically goes like this: take a bunch of new medical grads, throw them out on the wards, throw a few didactics a week at them that they may or may not be able to make it to because of how busy they are, and see what happens. There just isn't much teaching. Worse, there seems to be a major emphasis placed on 'evaluation' over 'teaching' (or just about anything else). Search through the medical education literature...there are a bazillion articles on 'evaluating residents' and far fewer on 'teaching residents' or 'improving medical teaching' or 'helping residents learn' etc. Often times I feels as though if half the effort placed on evaluation was placed on actually teaching the damn trainees, a lot of this would not happen in the first place.

And as for the above discussion...yeah, I really loved being dumped out in the ICU on my first overnight call with barely any training on managing the vents aside from what I'd been able to cobble together from a few random books etc. Getting chastised the next day for not doing everything right felt great too. I'm not surprised so many of these resident terminations start with an ICU misfire...it's a hell of a challenging environment where survival depends on a lot of skills that many medicine residents don't focus on and/or aren't particularly strong with. 11 of 12 rotations as an intern were non-ICU, but somehow I'm supposed to step into the ICU as a resident and do it all perfectly...riiiiiiight.

 

[johndoe44]

Wow, okay I see that a lot of people are speaking on my behalf so I guess I should actually say a few things.

I honestly do feel that this overall has been tremendously helpful for me to move forward and definitely some sound advice. But I kinda feel obligated to give some advice to others who may be experiencing something similar. This may be cheesy so I apologize in advance:

I believe that things happen. I do NOT believe that "everything happens for a reason," and if you think that I'm not sure why you do? If that makes you feel better then that's great but just know that things happen ( AKA S&^T happens). No matter how bad I wish this didn't happen is inconsequential-- the old saying "wish in one hand and **** in the other and see which one fills up quicker." That is just me being pessimistic.

However, I also believe that you choose how to react to these situations. You can choose to wallow or choose to move forward and do something else. I choose moving forward. I have to say that after all of this, what I realized is that my wife, family and friends are huge supporters of me regardless and that is all I need to move forward. I am happy because there are people around me who make me happy. I think at the end of the day this is honestly the only thing that matters. Had I not had a supportive group of people around me, I would be very unhappy and likely helpless. So, to say the least this experience has put everything into perspective. I guess it's hard to see at first but there are so many miserable people at that hospital that I see every day. Physicians with enormous bank accounts, nice cars, nice homes and felt that being a doctor was going to be the thing that makes them happy in life. Trust me, they aren't. Many are divorced, have issues with prioritization, never see their children, hate patients, never smile, awkward to speak with and just overall suck. I don't know how else to put it. They just simply suck. They suck as doctors, they suck as fathers/mothers, suck as colleagues and they especially suck at teaching.

BTW, do you know what doctor means in Latin? It doesn't mean healer, it doesn't mean smart, it doesn't mean entitled, it doesn't mean rich; it doesn't mean any of that. The literal docēre translates simply = to teach.

I actually was a high school teacher before I went to medical school and I really enjoyed it. Every year I would always tell the seniors:

"It was a pleasure teaching all of you. Just so you know, I am confident that each of you will do incredible things and I am so proud to have been a part of that process. I think it's important that you also know that something terrible will likely happen to you along the way; maybe even more than once. Remember that the only thing that really matters is whether or not you are happy and enjoy your lives. I can tell you there are plenty of people with fame and fortune that are starving for happiness. Not all your dreams will come true but if you pursue happiness, then your dreams will always come true."

I loved teaching and enjoyed teaching the medical students I was with. I am sure that I will get over all this and find something that is a better fit; IM or not. At the end of the day I am happy and thankful for the people I have around me. I am thankful for my wife and family who stand with me. Honestly, I'm just happy. No matter what happens I will continue to be happy because I have so many things to be happy about. I tried to feel the same way about medicine and it just doesn't quite make me all that happy. I look at my MD and continuing residency as a means to an end and not a source of pleasure. I think many people who are intelligent go into medicine thinking this will be what will finally make them happy, famous, rich, sexy etc only to realize they are the same person they were before, alone with a book and still searching to find some kind of meaning to their lives. Wielding some sort of imaginary power over their minions to compensate for their misery.

If I learned anything from this experience its how NOT to be a physician.

 

[pathperson]

OP, definitely what you just said. Yep. How NOT to be a physician.

I feel like in med school and residency, I met a few people along the way whose sole purpose in my life was to show me how NOT to act. How NOT to care for patients. How NOT to teach or treat people. I'm lucky in that these people were few and far between. But when you meet the attendings, nurses etc who just suck at life like you said, it just engrains in your memory forever....

The very sad thing about medical training is that there are so many negative experiences, they seem to overshadow the positives. There are so many awful teachers they seem to drown out the good ones. I had some true greats. And some who I just thought, WOW. if I can manage NOT to emulate that person, EVER, I will be awesome. I will avoid becoming a complete wiener.

Also true about the milestones. Whoever said that. Yep. They just rank you wherever you're supposed to be. Minus a tiny bit in some areas so you can have "room for improvement." Oh lookie here! You need to read more journals And integrate that into your service work. Next rotation, I won't have worked with the person who said that, won't have discussed a single paper with them, but they bump me up in that category bc it's where I'm supposed to be. It's irrational and stupid. We were a pilot site for milestones. It's dumb.

We are indentured servants. Which is one reason I do not think people should feel badly if they choose to have a baby as a resident. Which is what I tried to tell the married intern on here who got pregnant and was considering an abortion. WHY??? So you can be the most awesomest slave ever?? Wieners hate trainees. They won't give you a gold star for having an abortion. They will still pick on you. Even if you and your husband give up your baby for them. What can you say, " how dare you say I'm not good enough, don't you know I had an abortion so you would all see how hardcore I am?" Don't think so.


Oh,a and they (the wieners) focus on evaluations of every breath you take to keep the focus off their teaching. It's pretty obvious.

You don't have to hold my hand or worship me. But if there is one person who always says negative things, always, to the point of being irrational, I don't take that person seriously. Don't sacrifice rationality for negativity just to be negative. It means smart people won't listen to you anymore. The feedback is not meaningful.

 

[Law2Doc]

OP, definitely what you just said. Yep. How NOT to be a physician.

I feel like in med school and residency, I met a few people along the way whose sole purpose in my life was to show me how NOT to act. How NOT to care for patients. How NOT to teach or treat people. I'm lucky in that these people were few and far between. But when you meet the attendings, nurses etc who just suck at life like you said, it just engrains in your memory forever....

The very sad thing about medical training is that there are so many negative experiences, they seem to overshadow the positives. There are so many awful teachers they seem to drown out the good ones. I had some true greats. And some who I just thought, WOW. if I can manage NOT to emulate that person, EVER, I will be awesome. I will avoid becoming a complete wiener.

Also true about the milestones. Whoever said that. Yep. They just rank you wherever you're supposed to be. Minus a tiny bit in some areas so you can have "room for improvement." Oh lookie here! You need to read more journals And integrate that into your service work. Next rotation, I won't have worked with the person who said that, won't have discussed a single paper with them, but they bump me up in that category bc it's where I'm supposed to be. It's irrational and stupid. We were a pilot site for milestones. It's dumb.

We are indentured servants. Which is one reason I do not think people should feel badly if they choose to have a baby as a resident. Which is what I tried to tell the married intern on here who got pregnant and was considering an abortion. WHY??? So you can be the most awesomest slave ever?? Wieners hate trainees. They won't give you a gold star for having an abortion. They will still pick on you. Even if you and your husband give up your baby for them. What can you say, " how dare you say I'm not good enough, don't you know I had an abortion so you would all see how hardcore I am?" Don't think so.


Oh,a and they (the wieners) focus on evaluations of every breath you take to keep the focus off their teaching. It's pretty obvious.

You don't have to hold my hand or worship me. But if there is one person who always says negative things, always, to the point of being irrational, I don't take that person seriously. Don't sacrifice rationality for negativity just to be negative. It means smart people won't listen to you anymore. The feedback is not meaningful.

First, it's too bad you met so many "wieners" along the way, and I agree with you that the milestones and evaluations based on them are more or less window dressing for the files.

However I'm not sure the indentured servitude comments, issues with having kids during residency etc are ringing true. Why? Because you seem to be looking at it as doing what the "wieners" want, for them. But It's not about them. Never was and never will be. It's a gauntlet YOU must run through for YOU, and YOU alone. The training is hard and you may deal with difficult people along the way. But nothing you are doing here is about them and to be honest their being difficult on you is not bad training for a career where you inherently see people at their worst. They are like a mean drill sergeant always screaming and making you drop and do twenty pushups -- you don't like them but your training needs one. Or a tough coach on a sports team, barking at you to give them your "110%". yes they are jerks but yes to be well trained the happy go lucky guy who doesn't push you isn't always the guy who gets you to where you want to be. I guess a lot of nontrads come at it from a very different perspective -- the jerks in medicine are kind of lightweights in the world of jerkdom. Nobody is an indentured servant in medicine but a lot of us intentionally push through unpalatable situations and make certain career decisions to get to certain targets. Most of us asked to be here and as much as some of us like to bitch and whine, it's pretty voluntary that we are staying. we are getting more out of the relationship than the wieners are -- few indentured servants could say this.

Of course if you end up getting kicked out/non renewed that's a totally different and often unrelated story. It usually doesn't have as much to do with someone being a Jerk and more to do with some situation, real or perceived, where the working relationship isn't working out. Most people do fine working with jerks for years. And many of the people who let residents go were perfectly nice to residents up until the breakdown. So I think you might be mixing unrelated concepts.

 

[atomi]

Yeah...see this is what bothers me about what residency training has turned into. Many, many programs out there (even 'good ones') seem to operate under a format that basically goes like this: take a bunch of new medical grads, throw them out on the wards, throw a few didactics a week at them that they may or may not be able to make it to because of how busy they are, and see what happens. There just isn't much teaching. Worse, there seems to be a major emphasis placed on 'evaluation' over 'teaching' (or just about anything else). Search through the medical education literature...there are a bazillion articles on 'evaluating residents' and far fewer on 'teaching residents' or 'improving medical teaching' or 'helping residents learn' etc. Often times I feels as though if half the effort placed on evaluation was placed on actually teaching the damn trainees, a lot of this would not happen in the first place.

And as for the above discussion...yeah, I really loved being dumped out in the ICU on my first overnight call with barely any training on managing the vents aside from what I'd been able to cobble together from a few random books etc. Getting chastised the next day for not doing everything right felt great too. I'm not surprised so many of these resident terminations start with an ICU misfire...it's a hell of a challenging environment where survival depends on a lot of skills that many medicine residents don't focus on and/or aren't particularly strong with. 11 of 12 rotations as an intern were non-ICU, but somehow I'm supposed to step into the ICU as a resident and do it all perfectly...riiiiiiight.

I had a major issue with this as well as a new intern. I received terrible feedback on my evaluations from my first week as an intern. That I was not performing at the expected level, appeared "stressed" (are you freaking kidding me?), etc. Well, what exactly are you saying guys, that I should not have graduated medical school? Because you all haven't taught me anything yet. How can you evaluate me on anything other than showing up on time when I haven't been taught anything? Ridiculous.

 

[johndoe44]

LOL, agree with atomi. Some attendings teach nothing (in my case in the ICU) and then they question my medical knowledge? We will probably just go round and round with this topic because in the end, the attending's impressions and whatever they choose to write in the comment box is the only thing that matters I guess.

Last thing that I will note is that once you are "stamped" with any verb or adjective " unintelligent, lazy, boisterous, dangerous, quiet, shy, egomaniac" this will carry with you no matter what you do from that day forth. It's more like a high school setting than a hospital setting. Just today, I had an attending say that I would get a LoR but just wanted me to know that she had to include my "fund of knowledge" problem in the letter.... I worked with this person 6 months ago and somehow she found out that I have a "fund of knowledge problem." Like a rumor mill. Anyways, I sent her my CV with my recently received step 3 score which was , like all the others, above the national average. I guess objective evaluations like the USMLE is really off the mark when it comes to evaluating medical knowledge and patient management. I'm glad we have a good subjective system in place for people like me who might otherwise slip through the cracks.

 

[Raryn]

I had a major issue with this as well as a new intern. I received terrible feedback on my evaluations from my first week as an intern. That I was not performing at the expected level, appeared "stressed" (are you freaking kidding me?), etc. Well, what exactly are you saying guys, that I should not have graduated medical school? Because you all haven't taught me anything yet. How can you evaluate me on anything other than showing up on time when I haven't been taught anything? Ridiculous.

There's a bare minimum expectation that anyone who has been through medical school (hell, anyone who has been through m3 year) should be able to meet. That is significantly above showing up on time. If you can't evaluate a patient, get at least most of an H&P done, and organize it into at least a semblance of a presentation then yes, you probably shouldn't have graduated medical school. That doesn't mean you can't miss anything on your H&P, or that you have to have a comprehensive A&P that is exactly what your attending would have done. But yes, there's an expectation of a modicum of competence and an "expected level" for the intern. Even on the first day. Especially by the end of the first month.

 

[johndoe44]

Blah blah blah ......

To be a good med student, get high step scores, get a chill prelim and match radiology or anesthesia and play golf.

H&Ps are best done by the ER doc because it's 3 lines and they already do the entire work up.

 

[Arcan57]

Blah blah blah ......

To be a good med student, get high step scores, get a chill prelim and match radiology or anesthesia and play golf.

H&Ps are best done by the ER doc because it's 3 lines and they already do the entire work up.

?

Also, Step III is not an achievement test but a minimum standard required for licensing. Unlike the first 2 steps, essentially no one cares what they got on Step III as long is it was above passing and I cannot recall ever disclosing my Step 3 while applying for jobs, etc. So having a Step III above the national average is fine, but in no way means that you don't have a fund of knowledge deficiency in any given field. I would take someone emailing me their Step III scores to prove their fund of knowledge is adequate as an example of someone that profoundly misses the point.

 

[pathperson]

First, it's too bad you met so many "wieners" along the way, and I agree with you that the milestones and evaluations based on them are more or less window dressing for the files.

However I'm not sure the indentured servitude comments, issues with having kids during residency etc are ringing true. Why? Because you seem to be looking at it as doing what the "wieners" want, for them. But It's not about them. Never was and never will be. It's a gauntlet YOU must run through for YOU, and YOU alone. The training is hard and you may deal with difficult people along the way. But nothing you are doing here is about them and to be honest their being difficult on you is not bad training for a career where you inherently see people at their worst. They are like a mean drill sergeant always screaming and making you drop and do twenty pushups -- you don't like them but your training needs one. Or a tough coach on a sports team, barking at you to give them your "110%". yes they are jerks but yes to be well trained the happy go lucky guy who doesn't push you isn't always the guy who gets you to where you want to be. I guess a lot of nontrads come at it from a very different perspective -- the jerks in medicine are kind of lightweights in the world of jerkdom. Nobody is an indentured servant in medicine but a lot of us intentionally push through unpalatable situations and make certain career decisions to get to certain targets. Most of us asked to be here and as much as some of us like to bitch and whine, it's pretty voluntary that we are staying. we are getting more out of the relationship than the wieners are -- few indentured servants could say this.

Of course if you end up getting kicked out/non renewed that's a totally different and often unrelated story. It usually doesn't have as much to do with someone being a Jerk and more to do with some situation, real or perceived, where the working relationship isn't working out. Most people do fine working with jerks for years. And many of the people who let residents go were perfectly nice to residents up until the breakdown. So I think you might be mixing unrelated concepts.

I agree with you. It's not about them. That's why I say: don't let them run your life. Live your life if you can, while in training. Get married if its what you want. Start a family. Yes. Keep running marathons, whatever you do to stay sane, creative etc outside work.

I was not specifically addressing dismissal, though that is the point of the thread. I met very few nasty attendings as a student and resident. Those I met made a lasting impression. I have no actual personal experience with dismissal. So I can only speak to what is probably a pretty average training and educational experience.

As for whether residency is servitude or not, it doesn't matter. It is obviously voluntary, sure, and I'll leave it at that.

What is sad is when training is so harsh people cannot hold it together and previously strong extremely high achievers wind up killing themselves. I saw this in my med school classmate. AOA, the works. Couldn't pick a speciality. Entered a Monthlong downward spiral and could not get back to reality. A permanent solution to a temporary problem.

The problem I have is with the hierarchy in medicine. You're absolutely right it is like the military. There's an attitude of, if you can't beat 'em, join 'em. So by the time a person is finished, they're so tired and beaten down, plus they have a lot of new responsibilities as an attending, so things don't change overnight.

And then when they do change, they bring in silliness like the milestones. Once the milestones really sink in, people will just think, if this is what the future holds, please please no more changes!!!

 

[Law2Doc]

Blah blah blah ......

To be a good med student, get high step scores, get a chill prelim and match radiology or anesthesia and play golf.

H&Ps are best done by the ER doc because it's 3 lines and they already do the entire work up.

If you showed up with this attitude it's becoming less of a wonder why you had issues.