Is this a red flag?

[epsilonprodigy]

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I recently interviewed at a program that I really liked. The residents seemed to get along and we're thrilled with the teaching quality and case volume. I clicked with a couple of them in particular and eventually felt comfortable asking about attrition. Turns out they've lost 4 categorical residents in the past 4 years (class size 4-5.) sounds like 2 were mutual dislike, and were helped by the program to get into other specialties within the same hospital system. One was fired for very serious behavioral issues which left the program with no choice, from the sounds of it. The most concerning part: one was "fired for not cutting it" and "made some bad decisions." Although he was helped to match into something else, it does NOT sound like this was mutual.

Now I understand the difference between accidentally forgetting to cover for anaerobes and say, erroneously deciding to throw a surgical airway into someone the first week, but is this a bit of a red flag? Without meaning to judge unfairly, isn't learning (and sometimes making mistakes) supposed to be what residency is about? Clearly I don't have all the details, but it seems that a couple of bad decisions as a sole grounds for firing could create a pretty scary learning environment. Thoughts?

 

[Winged Scapula]

You don't have enough information to go on.

While it may not seem like it to students, it really is hard to get fired from residency. Thus, the vast majority of time it really is very serious issues, often dangerous ones, which lead a program to have no choice.

 

[doc05]

like it or not, remember that not every applicant is cut out for a surgical career. better they get fired than allowed to graduate.

 

[Wordead]

Gen surg attrition rate is 20% isnt it? Seems about right.

 

[epsilonprodigy]

Thanks for the responses. I realize my description is pretty limited. Since I got a good vibe in general, my plan is to keep it in the back of my mind, but still rank the program. Admittedly, a similar program with lower attrition would be even more attractive. After all (to be devil's advocate) shouldn't a program be able to filter out applicants that "aren't cut out for surgery?"

Anyone have examples of what firing-caliber errors might be? The boards are packed with one-sided tales of those who were canned because the PD didn't like their shoelaces, etc etc., but hearing an objective account is fairly rare.

 

[Winged Scapula]

Thanks for the responses. I realize my description is pretty limited. Since I got a good vibe in general, my plan is to keep it in the back of my mind, but still rank the program. Admittedly, a similar program with lower attrition would be even more attractive. After all (to be devil's advocate) shouldn't a program be able to filter out applicants that "aren't cut out for surgery?"

Devil's Advocate here: shouldn't medical schools do a better job of filtering out people who aren't cut out to apply for surgery? Shouldn't medical schools do a better job of preparing people for what their future fields are like?

One of the great criticisms of US medical education is that you are forced into making a decision about specialty before you really have enough exposure and you aren't exposed to a lot of specialties outside of the cores. Recent data show that 96% of surgical residency attrition is to resident change of heart.

Anyone have examples of what firing-caliber errors might be? The boards are packed with one-sided tales of those who were canned because the PD didn't like their shoelaces, etc etc., but hearing an objective account is fairly rare.

I'd venture the reason are mostly those of gross incompetence which is unremediable. In the 2 cases I am familiar with from my own residency, it was due to repeated episodes of lying (i.e., telling the PD who's on call that you're down in the ED with his patient right now, not realizing that the PD is returning your call from the patient's room).

 

[Pir8DeacDoc]

Short answer: you've gotta really do something stupid on more than one occasion to get fired. Legally it's not that easy to fire a resident.

 

[Goro]

I believe that you have mention using someone else login to email or chart is a fireable offence?

In my experience?

Theft from the hospital. Like literal theft, not like stealing graham crackers.

Repeated lying to co-residents and attendings which had to be meticulously documented before the GME would act on it.

That's it.

 

[Winged Scapula]

I believe that you have mention using someone else login to email or chart is a fireball offence?

Did someone say "fireball"? Yum..

Yes a HIPAA violation that can result in employment termination. I've seen it happen with nursing staff but not physicians so echnically yes it could happen. Like above, I was only commenting on those I've personally seen.

 

[vhawk]

I believe that you have mention using someone else login to email or chart is a fireable offence?

Oh man. At my residency it was SOP that if someone left their email logged into one of the computers, you automatically send out a program-wide email from said account that was extremely embarrassing. Sure glad I never got fired!

But yes, getting fired from residency is usually very, very hard to do. At my program we had one in the last 7-8 years and he just could not cut it as a surgery resident, he no-showed multiple times, he was unreliable, he failed to progress clinically over 3 years. He was a nice guy and was given chance after chance after chance, ultimately it just had to be done. We had several people remediate a year for lesser reasons, and one remediate a year (and ultimately graduate) for what I personally dont feel were "lesser" reasons at all. Its just not in the programs interest to fire anyone. It makes them look bad, it opens them up to a lawsuit, and all for what? So they dont unleash a dangerous person on the public? That sounds noble in practice but its a pretty minor negative as far as the program is concerned. And the idea that they care about their trainees "sullying their name" is a bit overblown to, as thye probably dont really care about this person who is gonna be sequestered in some podunk gen surg practice.

 

[Crayola227]

Getting rid of a resident is actually a lot easier than what anyone has said here.

There is an IMG just waiting to take your place if you get canned mid year, which they are looking to can people sooner and sooner for that reason if it's gonna happen. It's never too early to start worrying for your job intern year.

 

[Mad Jack]

Did someone say "fireball"? Yum..

View attachment 197323

Yes a HIPAA violation that can result in employment termination. I've seen it happen with nursing staff but not physicians so echnically yes it could happen. Like above, I was only commenting on those I've personally seen.

Aren't they usually like, blatant and awful HIPAA violations? Not just your garden variety "we were talking about a patient in too public of an area and a third party overheard some details," but like, looking into the charts of people you know, patients that made the news, or people who are famous? Or swiping medical information for more nefarious purposes?

 

[Pir8DeacDoc]

I held a leadership position with the gme during residency. It's hard to be fired. At least it was at our hospital.

 

[vhawk]

Getting rid of a resident is actually a lot easier than what anyone has said here.

There is an IMG just waiting to take your place if you get canned mid year, which they are looking to can people sooner and sooner for that reason if it's gonna happen. It's never too early to start worrying for your job intern year.

Yes, if there is one thing that US academic general surgery training programs are itching to do, it is build a reputation of firing residents mid year and replacing them with IMGs.

 

[Crayola227]

Was a direct insult really necessary?

You insinuated that I just give crap advice and that you are not rude and condescending to others. I thought I would check that out. Sure enough, another thread about resident dismissal and here you are directly insulting me.

 

[Crayola227]

OP -

I know a very small program that lost about 5 residents in 3 years. For BS reasons. Each time they just put out an ad and got an IMG within a few months.
It was a scheduling nightmare but that was that.

This is to say nothing of the kind of scuttlebutt I picked up as you did along the trail. That I dismissed as people here suggest. Then you and your friends start training and more dirt emerges.

The official Kool Aid will always be the right of the admin vs the scum of the earth residents.

 

[Crayola227]

.

 

[Winged Scapula]

OP -

I know a very small program that lost about 5 residents in 3 years. For BS reasons. Each time they just put out an ad and got an IMG within a few months.
It was a scheduling nightmare but that was that.

This is to say nothing of the kind of scuttlebutt I picked up as you did along the trail. That I dismissed as people here suggest. Then you and your friends start training and more dirt emerges.

The official Kool Aid will always be the right of the admin vs the scum of the earth residents.

****ty programs hire ****ty residents and do ****ty things to them.

That fact does not represent the majority of residency programs where getting fired is difficult.

Let's practice some EVIDENCE based medicine rather than fanning irrational fears.

 

[Crayola227]

I liked your post because you disagreed with what I said without insulting me or putting me down. Thank you for that.

I do not wish to fan irrational fears. However, the dismissals, resignations, terminations of people I know personally, coupled with more tales told to me directly by my co-residents recent tales but before my time, coupled with tales coming in from my former classmates now residents, and threads here on SDN have led me to this conclusion:

The reality for admin is that it is likely that is it difficult to fire a resident as y'all say. It doesn't happen often, sure. However, it appears also that there are certain programs where this sort of thing gets clustered. Woe to the resident who ends up there.
The subjective experience that the terminatee seems to experience is that after reassurances to how difficult it would be to fire them, it was surprisingly easy. I've heard it echoed on this board these theories meant to reconcile administrative reality with their "flawed" perception: they were in denial, clueless, all the signs were there, had warning didn't take seriously enough, etc.

I wouldn't be surprised if the people getting canned were the ones not taking things seriously enough. That could be hubris or just a lack of info. So I guess saying it's easier to get fired then you think is a statement that depends on your perspective.

In any case, I see more students and residents harmed by some perception of security and that getting in/graduating/matching = set for life, than I see irrational fears holding them back. Toe the line keep your head down and yes, I would be concerned if the situation is such at a program that the residents there seem to have concerns about the losses the program has sustained.

TLDR:
I think it's common sense to readers confused by our exchange to suggest this:
The programs where the admin and residents react against what I have said, sounds like those are the places to be, where terminations are uncommon, difficult, people scoff about them etc, like where Winged Scapula and others are
The programs where residents can't help but whisper about them to you, a total stranger at dinner ostensibly being recruited to be their next victim I mean work buddy, and where you have residents lamenting the ease with which good people got shoved out as a pattern, well, malignant programs are about as common as pancreatic cancer which is to say they aren't, but you still try apply preventative and predictive strategies because bad outcomes however uncommon are still bad. The disparity in what I am saying and what others are saying could well represent the very spectrum that exists in programs, which you are trying to uncover as you interview. Don't believe everything you hear and take your job very seriously.

 

[Arcan57]

Devil's Advocate here: shouldn't medical schools do a better job of filtering out people who aren't cut out to apply for surgery? Shouldn't medical schools do a better job of preparing people for what their future fields are like? One of the great criticisms of US medical education is that you are forced into making a decision about specialty before you really have enough exposure and you aren't exposed to a lot of specialties outside of the cores. Recent data show that 96% of surgical residency attrition is to resident change of heart.

I'd venture the reason are mostly those of gross incompetence which is unremediable. In the 2 cases I am familiar with from my own residency, it was due to repeated episodes of lying (i.e., telling the PD who's on call that you're down in the ED with his patient right now, not realizing that the PD is returning your call from the patient's room).

Agree with point above. There is only a casual attempt to bridge the gulf between med student perception of specialty x and attending experience of specialty x. This leads to disillusionment, wasted time and training, and makes the adjustment from student to intern even rougher due to anxiety regarding appropriateness of specialty choice. While it's time that's not useful for grading, perhaps a system where students shadow attendings for a couple of days during each rotation would result in a more complete understanding of the day to day that specialty deals with. Depending on junior housestaff to impart an accurate view of the specialty while they themselves are still trying to figure out clinical medicine is a system that (mostly) works by accident rather than design.

 

[Crayola227]

There may be a difference in perspective between you and other posters. Specifically, the distinction between being fired and resigning. My program has fired multiple residents. Of course, none of them were actually fired, all resigned. We refer to them as being "fired" because we knew the circumstances.

I suspect it is far easier to "convince" a resident to resign than it is to formally terminate them.

Exactly right. It's not hard to drum up enough evidence/pressure/threats to get people gone. Threats to be reported to the state licensing board work rather nicely, as well as implications that the PD is not going to have anything nice to say about you in a letter or over the phone to anyone involved in your career ever are really good motivations to go quietly. Not always, sometimes there's attorney playtime in the sandbox.

And of course, there's a hundred reasons programs don't want to play that get-the-resident-gone game and yeah, losing your job isn't a common occurrence. Still want to see all these future residents toeing the line just because the stakes are crazy high.