List of Programs That Terminate Residents

[3dtp]

This thread is important. In the past there were a number of "hints" that a program was problematic. Freida, the spawn of the ill-reputed AMA used to have a question on its data form Entitled: Program completion rate followed by a percentage. Anything less than nearly 100% would be suspicious in my book and certainly reason to ask pointed questions to the PDs before wasting money on ERAS slots.

I now note that AMA/FREIDA no longer lists this statistic. They simply report YES/NO, in the Program evaluation session.

So, I looked at other statistics and found something interesting. In listing a specialty residency slots by PGY, some programs are pretty uniform and constant:

IE Program A:
PGY1: 20
PGY2: 10
PGY3: 10

While another Program B:
PGY1: 25
PGY2: 12
PGY3: 9

In both of these cases, the programs offer a "preliminary" year which explains the drastic differences between PGY1 (intern) and PGY2. In Program A example, PGY2 and 3 are the same, and is probably a reasonable indication that the program intends to honor its commitment to its trainees and do its best. As others have said, if you get through med school, have good character and pass the Steps, you are trainable.

Consider program B: Again, PGY1/PGY2 differences not so worrisome, but why is the PGY3 position 3 shy of the PGY2 position and what happens to the PGY2 three who do not apparently have slots? Attrition at PGY3 level? or is this program a musical chairs game and you'd better be good or you won't have a seat when the music stops?

If I were looking at a program such as B, you can better believe that if I were looking at programs, the PD would be called prior to ERAS submission to ask specifically how this program worked and why there was a discrepancy between slots.

Some years ago, I looked at programs that were identified in a survey of PGY1s/MS4s as "malignant." One of the characteristics I looked at was the FREIDA reported program completion rate. There was a correlation between higher malignancy reports and lower program completion rates.

Serendipity? Perhaps. I had no means of determining true correlation, so at this point this is just an observation which may or may not be related.

Unfortunately, AMA, bastion of integrity that it is, no longer publishes this number. Had it continued that number, it would have been an interesting study of the list being compiled here. In my original, admittedly not particularly rigorous survey/comparison of 300 med student -> PGY1 and examination of the Program Graduation Rates value, a value of less than 96% was a large red flag.

All programs will have problems from time to time, and all residents will have problems from time to time. People get sick, pregnant, have car accidents, or someone dies. They need time, and these events will be reflected in that statistic, but when that statistic passed a threshold, it was a big red flag for a program that might be a rattlesnake in disguise. Just what this threshold might be is indeterminate.

Another interesting thing I learned: FREIDA used to report program Vacation/Leave time in days off/year. I learned from that survey that some institutions were craftily dishonest. They reported 14 or 21 days off. Then required residents to take the time in 8 or 9 day minimum blocks. So, 14/8=1 week, and so sorry, but you only have 6 days and policy is 8 day minimum. Net result: 1 week. I note that FREIDA now reports time in weeks, which hopefully quashed that bit of program dis-ingenuity.

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[docu]

what about physician re-entry programs:

http://www.ama-assn.org/ama/pub/education-careers/finding-position/physician-reentry.page

do they really help displaced residents get back into the system? Has anyone seen true story examples of this?

 

[peerie]

I think that Substance has it right, the comments s/he made are very spot on in my opinion and very well expressed.

This is a real situation and one that will not go away as long as the system is becoming one of supply and demand. With so many people wanting these residency spots there will continue to be an intense pressure to perform and if not then just be replaced. Good programs will take pride in their trainees and maybe even care about them. What a great investment! Other programs may yield to the hospital pressures to produce income at the expense of training.

Remember, a fully trained and experience physician from another country can be a great resident to have, you don't need to teach them really and they can perform very well from the start. Also - they will not challenge you because they want to get their license. So, hardworking, previously trained and silent. How much income does a good resident generate for a hospital? maybe 100,000 a year? Plus the $130,000 they receive from the government, minus whatever they pay the residents.

Medicine is in trouble on many fronts, not the least is our weakening training system. It is increasingly driven soley by money - ask any practicing physician. The burden on residency programs is that there are close to 40,000 applicants a year now and only the 25-26,000 positions available. 16,000 of whom are US grads. The numbers are troubling on many fronts, medicine is really struggling.

 

[peerie]

what about physician re-entry programs:

http://www.ama-assn.org/ama/pub/education-careers/finding-position/physician-reentry.page

do they really help displaced residents get back into the system? Has anyone seen true story examples of this?

No, they do not. This is a bitter pill even for even for very experienced physicians who want to return. Does paying $12-16,000 seem reasonable to you or does that sound sort of exploitive?

Trust your instincts on this one, if it sounds kind of strange then maybe it really is.

 

[NotAProgDirector]

While another Program B:
PGY1: 25
PGY2: 12
PGY3: 9

Consider program B: Again, PGY1/PGY2 differences not so worrisome, but why is the PGY3 position 3 shy of the PGY2 position and what happens to the PGY2 three who do not apparently have slots? Attrition at PGY3 level? or is this program a musical chairs game and you'd better be good or you won't have a seat when the music stops?

If I were looking at a program such as B, you can better believe that if I were looking at programs, the PD would be called prior to ERAS submission to ask specifically how this program worked and why there was a discrepancy between slots.

Although I agree with your assessment, there are good reasons why there might be less PGY-3's than PGY-2's. Residents in an IM research track exit after their PGY-2, for example. Hence, I would not assume that all such discrepancies indicate a problem.

what about physician re-entry programs:

http://www.ama-assn.org/ama/pub/education-careers/finding-position/physician-reentry.page

do they really help displaced residents get back into the system? Has anyone seen true story examples of this?

You misunderstand the purpose of re-entry programs. They are to help fully licensed physicians who have taken an extended break from work to get back into the workforce. They are not designed to help displaced residents.

 

[docu]

You misunderstand the purpose of re-entry programs. They are to help fully licensed physicians who have taken an extended break from work to get back into the workforce. They are not designed to help displaced residents.

For the re-entry program, the PD at Drexel stated: Participation in this course does not guarantee you will obtain a residency, however, several past participants were successful obtaining a residency spot. As a reminder, I strongly suggest that you talk with a residency director to see if this opportunity will improve your competiveness. Thus, displaced residents can do this program. However, the cost is $7,500 which is pretty steep.

As for additional info on this program:

The Drexel Medicine® Physician Refresher Course, a formal course of study, that numerous physicians have taken prior to applying to a residency program.

Structured Preceptorship is offered in six-week rotations. We have Preceptorships in internal medicine, pediatrics, Ob-GYN, and some surgical subspecialties. During the Structured Preceptorship, the observer (observer only, no hands on) participates in inpatient and outpatient rounds, core conferences, lectures and learns about integrative, high quality medical care in the United States. In patient and outpatient experiences are scheduled to meet your interests and professional development needs. Inpatient rounds include ICU, CCU, medicine, endocrinology, etc. Outpatient rounds can include cardiology, nephrology, women's health, HIV/Aids, infectious disease, etc. In addition to inpatient and outpatient rounds you will attend didactics - morning reports, noon reports, grand rounds, and clinical case discussions. You also have a series of home work assignments including online diagnostic cases, patient physician communication exercises and history and physicals. Every week you meet with your preceptor to review the exercises and receive feedback on your progress.

 

[NotAProgDirector]

I stand corrected. I had assumed that these programs were for physicians who completed residency / were licensed, then took a long leave (to have a family, for example).

 

[peerie]

I stand corrected. I had assumed that these programs were for physicians who completed residency / were licensed, then took a long leave (to have a family, for example).

AProg is right. I believe that the experienced physician who is returning after time off is still their intended applicant and less so an overseas or US graduate seeking a residency position. If you ask programs they will admit that they do not advise participating in order to be more attractive to a residency program, there is simply no way to make that claim. But participating in these programs will definitely make you more employable as a seasoned physician with a break in practice. Most seasoned physicians still chafe at the price tag, tho, and will do anything to work/volunteer part-time in order to avoid this hassle.

 

[3dtp]

Although I agree with your assessment, there are good reasons why there might be less PGY-3's than PGY-2's. Residents in an IM research track exit after their PGY-2, for example. Hence, I would not assume that all such discrepancies indicate a problem.

There may be valid reasons for this, which are above reproach. But, then why does the FREIDA site constantly reduce measures which may help choose good and/or avoid bad programs?

My first thought in a post-menopausal bleed: cancer until proven otherwise.
Likewise, these discrepancies are malignant until proven otherwise, preferably with good and credible explanations prior to the ERAS submission dates.

 

[Winged Scapula]

But, then why does the FREIDA site constantly reduce measures which may help choose good and/or avoid bad programs?

Uhm...because FREIDA is operated by the AMA and ACGME?

 

[morn]

.

 

[3dtp]

Uhm...because FREIDA is operated by the AMA and ACGME?

Touche.

 

[mohammad1975]

There was misinformation from the source regarding this post. This should be changed according to the updated information. please disregard this message and rely on accurate information which is posted on ACGME website.

 

[docu]

how about the entire US nation of doctors, residents, and medical students file a suit against ACGME to change the practices for the better and end all the corruption of this monopoly. We could win in large numbers.

 

[MD forever]

how about the entire US nation of doctors, residents, and medical students file a suit against ACGME to change the practices for the better and end all the corruption of this monopoly. We could win in large numbers.

This problem affect small percentage, compared to all residency training programs, though seems to be growing, still it minor issue compared to GME. Please get out the victim role and the associated drama, try to move on with your career. I wish you all the best, Here I may add one suggestion; if it did not work for you here, try other countries, (e.g) Australia, New Zealand decent countries right! they accept the USMLE as an entry route option, If you have two years of ACGME residency in the US, they are willing to take you in, and work there, also your interrupted training can be completed there. It just a thought wanted to share you, understand completely if did not match your goals.

 

[docu]

This problem affect small percentage, compared to all residency training programs, though seems to be growing, still it minor issue compared to GME. Please get out the victim role and the associated drama, try to move on with your career. I wish you all the best, Here I may add one suggestion; if it did not work for you here, try other countries, (e.g) Australia, New Zealand decent countries right! they accept the USMLE as an entry route option, If you have two years of ACGME residency in the US, they are willing to take you in, and work there, also your interrupted training can be completed there. It just a thought wanted to share you, understand completely if did not match your goals.

this is not a minor problem....let say 3 americans are held hostage in a foreign country...doesn't the US do everything in their power that justice is served? well same should be true for this problem. you can't let injustice prevail even if it happened to a small quantity.
lets say an african american was discriminated against, well should he let it go because he's only one of him? AA's were a minority and they didn't have rights before someone stood up for them, like Rosa Parks. so definitey, he was wronged and he should stand up for his rights. injustice should not be tolerated whatsoever, no matter how 'small' the problem is. Also, if this happens to to hundreds to thousands of residents per year, this is not a small problem at all. it is a major problem.

 

[docu]

interesting list of places that terminate: http://www.jdunderground.com/mdunderground/thread.php?threadId=9091

 

[NotAProgDirector]

how about the entire US nation of doctors, residents, and medical students file a suit against ACGME to change the practices for the better and end all the corruption of this monopoly. We could win in large numbers.

What exactly do you want the ACGME to change? The ACGME instituted work hour limits and other protections for residents, and trust me many programs were very unhappy about that. I realize (from your other posts) that you feel like you've been mistreated by your program. But how is this the ACGME's fault or responsibility?

 

[docu]

the ACGME allows program directors to do whatever they want to a resident and do nothing to help the resident. there are no checks or balances. the system is flawed in that respect. i dont know who should be sued, but it should be whoever is allowing resident termination and dismissal to occur even in unfair situations. i do understand there are some residents that deserve termination, but a lot of times those that don't deserve termination often fall into the mix. i dont know, what do you think? i just wish something could be done about the unfair dismissals.

 

[lizna]

I agree with the opinion of docu. I myself had been in the same unfortunate position as most of the residents(terminating residents) in this forum. Program directors terminate residents mostly for their own grudges rather than true lack of a young doctor's knowledge or skills. No one should have the right to play with the careers of others especially when one has been successfully through med school, finished two or more years of training with out any deficiencies and proved to practice independently with out any issues.

My impression is since most of the PDs belong to the age group, when they had leisure of joining any program they wanted to and do not realize how hard now a days it is to find a training spot, pay off the loans and excel in the career. Once they terminate a resident basically what they put in their records is that this young doctor should not be allowed to practice, if a resident is overtly negligent in patient care, which rarely happens then this is a different matter, but merely dismissing someone on the basis of professionalism or other such crap is totally bias.

If a resident desires to study a specific area of medical specialty he should be allowed to do so, no PD should have a right to dismiss them.

 

[peach4me]

There should be adequate oversight!!

 

[NotAProgDirector]

This discussion has happened multiple times on SDN.

Evaluation of resident performance is a notoriously subjective event. There is no way to make it objective -- we've all seen residents whom look "fine" based upon standardized exams, but who don't do good work. I've also seen residents with borderline exam scores, and some of those do well and some don't. Perhaps the exam cutoff scores are too low -- but that's a different issue.

So, evaluation of residents is going to be difficult. Resident performance is often variable -- "poor performning" residents often to OK some of the time, and then not OK some of the time. That can be a difficult situation, as I may say to the resident that their performance is not acceptable, yet they will point to (other) evaluations which say that they are fine. Some of this is due to variable evaluator skill also.

That being said, I do agree that it would be nice to have some sort of "fair" review process for residents who struggle. However, how to make it fair is unclear. Any outside review board (whether it's the ACGME or something else) is invariably going to need to review what the PD says and what the resident says, and make a decision. It will always come down to a he said / she said situation, an outside authority is never going to be able to "figure it out fairly". There is no instant replay video to review. Or, if you really want some outside group to really evaluate the process, then it's going to be very time consuming and very expensive.

What I do think would be a potentially useful compromise would be for some central agency (perhaps the ACGME) to act as a clearinghouse for LOR's for residents whom are terminated / let go. They could receive / hold the letters, and perhaps even review the content of the letters to ensure that they accurately reflect what happened in the prior program. In addition, it would ensure that the letter was at least complete. But, in the end, I don't know how much this would really help.

Alternatively, programs could be required to publish (or have published for them) the number of residents who do not complete the program. This is difficult also, as residents may leave a program willingly for a number of non-sinister reasons.

I disagree with the statement that a PD shouldn't be able to dismiss a resident. It's my job to ensure that my graduates are competent. If I have a resident who has proven unable to meet that standard, I need to dismiss them. Changing the broken system we have now for one that can't dismiss anyone is just as crazy.

 

[Shinken]

Changing the broken system we have now for one that can't dismiss anyone is just as crazy.

After years of reading posts on SDN, basically the conclusion I reach is that dismissed residents:

1- have a sense of entitlement due to having spent "years" and "lots of money" on their education and therefore they deserve something in return for that investment of time/money, and...

2- dismissed residents are never at fault in their view. It's always a variation of "I was doing awesome and people told me daily how awesome I was and wham! out of nowhere they tell me they're not renewing my contract and the PD is out to get me."

It's unfortunate it happens, but in my very limited experience, the two residents I know that were dismissed from their residency programs really deserved to be dismissed. I would be scared to have them work as physicians.

 

[lizna]

"Any outside review board (whether it's the ACGME or something else) is invariably going to need to review what the PD says"
What if the PD is biased, or incompetent by himself, board is going to rely on his statements to judge for a career of a young doctor.

We all know that evaluations in medicine are relative and subjective, plus it is a life long learning process to master clinical skills, an outside board for resident termination evaluation must not take into account what one single man says, the "PD", an evaluation must be independent, must review the entire resident performance over years, must interview other residents, nursing staff and rely heavily on the evaluations and interviews with the attendings with whom residents interact "the most" during clinical rotations.

The unfortunate situation that I faced had a biased fact that I never worked or staffed a single patient with my ex-PD in 2.5 yrs, and towards the end he ended up terminating me for "lack of good interpersonal communication skills". He never observed me directly as how I interviewed my patients, how were my clinical skills and how good or bad was I a clinician.

ACGME must take this authoritative role away from one persons and divide it among various faculty members.

 

[chocomorsel]

After years of reading posts on SDN, basically the conclusion I reach is that dismissed residents:

1- have a sense of entitlement due to having spent "years" and "lots of money" on their education and therefore they deserve something in return for that investment of time/money, and...

2- dismissed residents are never at fault in their view. It's always a variation of "I was doing awesome and people told me daily how awesome I was and wham! out of nowhere they tell me they're not renewing my contract and the PD is out to get me."

It's unfortunate it happens, but in my very limited experience, the two residents I know that were dismissed from their residency programs really deserved to be dismissed. I would be scared to have them work as physicians.

My biggest problem with the system is that once you are "dismissed" or terminated, it is hard to move on. You always, always have to a have a PD letter in order to potentially move on to another residency. And of course, most likely it is not going to be pretty if you've been terminated. Therefore other PD'S are very reluctant to hire someone who's been fired from somewhere else previously.

In the real world you could be fired today and hired tomorrow because you have the option of letting your future employer not contact your previous employer. Of course they can choose not to hire you based on not knowing all your past history but most people are able to move on successfully without problems based on experience/education/interview etc. And if your previous employer says something negative about you, they can open themselves up to a lawsuit.

Why can't this also be the same in medicine? I feel that these options are non-existent in medicine. So if you did say 2 years of residency then got terminated and wanted to start over somewhere else why not just be able to provide 2-3 letters of rec from previous attendings who thought well of the resident and be able to move on based on previous medical school education/pre-residency employment/volunteering etc and leave out the crappy 2 years one might have had in residency.

Maybe APD can help me out here. This is my biggest beef with the system. It is extremely difficult to move forward whether it was a rightful termination or not. This is very unlike the real world. I have had previous jobs in the real world and was terminated and had no problems at all getting a new job.

 

[physicsnerd42]

My biggest problem with the system is that once you are "dismissed" or terminated, it is hard to move on. You always, always have to a have a PD letter in order to potentially move on to another residency. And of course, most likely it is not going to be pretty if you've been terminated. Therefore other PD'S are very reluctant to hire someone who's been fired from somewhere else previously.

In the real world you could be fired today and hired tomorrow because you have the option of letting your future employer not contact your previous employer. Of course they can choose not to hire you based on not knowing all your past history but most people are able to move on successfully without problems based on experience/education/interview etc. And if your previous employer says something negative about you, they can open themselves up to a lawsuit.

Admittedly, I'm stepping into territory that I don't have experience with yet and I'm probably not qualified to talk about (I'm currently finishing up my PhD before heading back to 3rd year of med school). Medicine, however, is not really the same as most other jobs. "Society" has made a pact with our profession. In that pact, physicians get to do things that other people can't: we can cut, irradiate and administer controlled drugs to people without going to jail. We also have a monopoly on doing many of those things. In exchange, we're supposed to ensure that those who practice medicine are competent and fit to practice; that's why every state has a medical board which is empowered to grant or deny a medical license to people with medical training. The reason we need state medical boards is that not everyone who has gone to medical school and completed 1+ years of residency is actually competent to practice medicine. As aPD pointed out, not everyone who enters a residency program is qualified to finish it. While program directors are supposed to try to remediate residents as best they can, they're also mechanisms by which people who shouldn't be practicing medicine are blocked from doing so, as part of our contract with society.

Is it fair that a PD can single-handedly destroy a career? No. At the same time, we all know that every person who starts a residency is not qualified to finish one. Some people actually would be a danger to patients if allowed to practice unsupervised. Part of the role of the PD is to judge whether someone is qualified to diagnose and treat illnesses. There's a difference between a person leaving a program because, for instance, they want to be closer to family and because the PD thinks that this person is unfit to practice medicine. The PD of whatever program they would like to go to needs to get the opinion of the previous PD to make an informed choice. This leaves open the possibility that an unethical PD could ruin someone's career without any legitimate reason but I don't see any way around that.

Despite all the threads on SDN about the topic, I don't get the impression that unjustified terminations of residents happen all the time. I have quite a few friends/family who are residents across the country and I've heard about residents in their programs not having their contracts renewed. Most of the time the sentiment from the residents I know is something along the lines of, "The PD tried their best to help the person get back on track, but this resident just wasn't getting it done." I'm sure there are unjustified terminations but I don't think it's the epidemic that many posters on here would have us believe.

If a resident desires to study a specific area of medical specialty he should be allowed to do so, no PD should have a right to dismiss them.

It's completely unreasonable to say that anyone should be able to do any residency they please and that no one should ever be fired; that would be a rubber stamp, not a training program. At that point, why even bother evaluating residents?

 

[lizna]

It's completely unreasonable to say that anyone should be able to do any residency they please and that no one should ever be fired; that would be a rubber stamp, not a training program. At that point, why even bother evaluating residents?

If you read my later post, I explained that the authoritative role of PD must be taken away and divided amongst faculty members who interact with resident the most during clinical rotations. If the faculty members of various sites/rotations come to a comon decision that a resident is performing unsatisfactory and could compromise patient care, then they should step in to decide in consensus among each other, whether that resident be allowed to continue to finish the program or be terminated.

 

[QofQuimica]

After years of reading posts on SDN, basically the conclusion I reach is that dismissed residents:

1- have a sense of entitlement due to having spent "years" and "lots of money" on their education and therefore they deserve something in return for that investment of time/money, and...

2- dismissed residents are never at fault in their view. It's always a variation of "I was doing awesome and people told me daily how awesome I was and wham! out of nowhere they tell me they're not renewing my contract and the PD is out to get me."

These are possibilities. But cultural and personal issues seem to be a major part of the problem. I doubt it's a coincidence that so many of the dismissed residents posting on SDN are non-American IMGs. The disconnect between these residents' sense of unfair termination and their programs' sense of professionalism issues may stem at least in part from the fact that, while these residents could be reasonably competent as physicians, they're not fitting into our medical culture very well. All the more reason, IMO, to continue increasing the number of American med school graduates so that we will have residents who have done their medical education here and are familiar with our system.

 

[RadOncDoc21]

I do agree that medicine is a different field and not every physician should just be promoted up the ladder without the proper number of procedures/training/scores but in my limited experience (pgy-2), a program director has too much power over a resident's career.

I had a situation occur during my intern year with my PD and none of it involved clinical assessment. Basically it was a misunderstanding but luckily I had the proper documents to justify the events that occurred. If I didn't have these, it would have been his word against mine and whose word do you think matters more?

I often think back to that situation along with my experience with other residents in the program and realize it really doesn't take much for your career to be ruined by one person.

I believe if you have other attendings/chief residents/ancillary staff who can support your clinical skills and work ethic, a letter from the PD should not hold as much weight.

-R

 

[NotAProgDirector]

What if the PD is biased, or incompetent by himself, board is going to rely on his statements to judge for a career of a young doctor.

This is my point completely. A review board will be limited by the information it receives.

We all know that evaluations in medicine are relative and subjective, plus it is a life long learning process to master clinical skills, an outside board for resident termination evaluation must not take into account what one single man says, the "PD", an evaluation must be independent, must review the entire resident performance over years, must interview other residents, nursing staff and rely heavily on the evaluations and interviews with the attendings with whom residents interact "the most" during clinical rotations.

ACGME must take this authoritative role away from one persons and divide it among various faculty members.

There are two ideas here. The first is to have any review committee do a "deep dive" -- to review multiple inputs, interview residents and faculty, etc. Although I agree that might help get a better sense of the situation, it's going to be very expensive and complicated. You'd probably need to fly experts in, spend a couple of days getting the information, write a report, etc. Who exactly would pay for all of this? The "ACGME" can't, or will need to extract more fees from programs for this -- possible but difficult. It would be very time and resource intensive. But, it could be something that residents push for. There are resident members on the ACGME -- you could certainly contact them.

The second is to change a "program director" to an "evaluation committee". This is a mixed bag, IMHO. First of all, it's likely to be dominated by a single person anyway. I doubt you would get the "mixed input / opinions" that you want.

I think the best option is to require PD's to submit their "overall assessment" letter to the ACGME. There could be a subgroup of the ACGME (including a resident member) who reviews these documents, and perhaps reviews input from the resident and perhaps from others. Much of this could probably be done over the phone (and hence would be relatively inexpensive). Still, I worry that the story over the phone will be very consistant and that this will still turn into a he said / she said issue. What exactly is the ACGME going to do if the PD and some faculty state that some resident is incompetent in some way, yet other faculty say they are fine?

I would note that the ACGME would likely not want to get into this as they would be potentially liable for lawsuits either way -- if they "agree" with the PD they could be sued by the resident, and if they "agree" with the resident they could be sued by a patient in the future if the physician has a problem.

It's a messy situation. I agree that some sort of check/balance on PD's is needed. I just haven't heard an idea that I think will really work yet.

My biggest problem with the system is that once you are "dismissed" or terminated, it is hard to move on. You always, always have to a have a PD letter in order to potentially move on to another residency. And of course, most likely it is not going to be pretty if you've been terminated. Therefore other PD'S are very reluctant to hire someone who's been fired from somewhere else previously.

In the real world you could be fired today and hired tomorrow because you have the option of letting your future employer not contact your previous employer. Of course they can choose not to hire you based on not knowing all your past history but most people are able to move on successfully without problems based on experience/education/interview etc. And if your previous employer says something negative about you, they can open themselves up to a lawsuit.

Why can't this also be the same in medicine? I feel that these options are non-existent in medicine. So if you did say 2 years of residency then got terminated and wanted to start over somewhere else why not just be able to provide 2-3 letters of rec from previous attendings who thought well of the resident and be able to move on based on previous medical school education/pre-residency employment/volunteering etc and leave out the crappy 2 years one might have had in residency.

Maybe APD can help me out here. This is my biggest beef with the system. It is extremely difficult to move forward whether it was a rightful termination or not. This is very unlike the real world. I have had previous jobs in the real world and was terminated and had no problems at all getting a new job.

I think you'll find the same issue in any highly compensated / highly trained field. It's unlikely that you'd be fired from some law or engineering firm, and simply go get a job at another firm. Part of the problem is that when you are hired as a resident, you are given a large amount of responsibility right at the beginning, which is a huge problem to fix if you have problems.

These are possibilities. But cultural and personal issues seem to be a major part of the problem. I doubt it's a coincidence that so many of the dismissed residents posting on SDN are non-American IMGs. The disconnect between these residents' sense of unfair termination and their programs' sense of professionalism issues may stem at least in part from the fact that, while these residents could be reasonably competent as physicians, they're not fitting into our medical culture very well. All the more reason, IMO, to continue increasing the number of American med school graduates so that we will have residents who have done their medical education here and are familiar with our system.

I agree with this. I would point out that cultural differences may explain problems, but they are not really an acceptable excuse. It is your responsibility to understand US culture prior to being hired. An interesting example: one of my residents in the past ordered a placebo for a patient. Where he came from, this was completely acceptable. To be honest, given the patient's story it was "reasonable" to try a placebo. However, that's considered unethical in our society. Although it's understandable given his background, it's still not acceptable.

 

[lizna]

I guess if I am not mistaken, there are quite a few US graduates here on this forum which are in the same shoes as IMGs are(termination), they probably have better chances of securing a future spot though.

Can ACGME appoint an ombudsman through the mutual agreement b/w residents and the faculty, who is affliated with the university but not with the program, and his reponsibilty would be to make sure that in cases of resident termination, the decision has been made in agreement amongst all the faculty members and these faculty members have interacted/supervised with the same resident in more than x number of rotations and in their opinion a resident performance is unsatisfactory.

I donot see why this is un doable or could be very expensive, though I do see it will take away the authoratative role of a program director.

 

[QofQuimica]

I agree with this. I would point out that cultural differences may explain problems, but they are not really an acceptable excuse. It is your responsibility to understand US culture prior to being hired. An interesting example: one of my residents in the past ordered a placebo for a patient. Where he came from, this was completely acceptable. To be honest, given the patient's story it was "reasonable" to try a placebo. However, that's considered unethical in our society. Although it's understandable given his background, it's still not acceptable.

I wasn't suggesting that it is an acceptable excuse. I do think, though, that eliminating most foreign IMGs from training in American residencies will help avoid many of these disconnects relating to professionalism. The example you gave would not have happened had that resident gone to an American med school, where he would have been taught American medical ethics principles.

 

[mohammad1975]

I have been reviewing these posts and especially our honored member, Mr. Program director. Based on experience and what I have read here so far, it seems like day after day, there are more concerns and problems in residency programs and it seems like these problems are growing every day!!!! Increasing the number of US grads is a good decision but just consider the fact that more and more IMG's do research and help medical system grow with their knowledge and experience. US medical system owes IMG's alot and those guys know it very well. Avergae US grad does not do that much research since he/she knows his/her spot is secure. But IMG does since he/she wants to secure a position, please do not deny it. If IMG's did not have any benefit, you would not use them. in the world of business (USA) everything is based on cost/benefit. I agree and also have been a victim of cultural misunderstandings. I believe that a good program director should be aware of everything that happens in his/her department...anything goes wrong, he/she should be aware and address at teh right time and right place, if sees no improvemnt, helps his/her resident find an alternative...(going somewhere else). Termination/retaliation is a childish decision that no one wants to see from a person who calls himself A DIRECTOR. Program director is like a president of a country, his/her actions count. I think the PD of the programs which their program has mentioned as malignant should come forward and explain...I believe once you got in residency you should finish it either in original place or somewhere else.

 

[member0007]

I have to jump into this mix. The PD can be changed by the hospital that you work at. They can have a PD who is pretty good but the hospital doesn't like this person for whatever reasons. They will get somebody else to be the new PD and someone who constantly complains about having the PD job and how no one tells him how to do his job, etc etc. This is like the worst situation ever for a resident because you rely on PDs for problems and mediation, as they come up, and it sucks if the hospital suddenly gives you a new PD who is just not up for the job and doesn't have enough common sense to help a resident in training. I think the hospital that has trainees are responsible for the PD that they assign and if you don't like him, complain to the hospital, very anonymously though ;-)

 

[residentdoctor]

This discussion has happened multiple times on SDN.



That being said, I do agree that it would be nice to have some sort of "fair" review process for residents who struggle. However, how to make it fair is unclear. Any outside review board (whether it's the ACGME or something else) is invariably going to need to review what the PD says and what the resident says, and make a decision. It will always come down to a he said / she said situation, an outside authority is never going to be able to "figure it out fairly". There is no instant replay video to review. Or, if you really want some outside group to really evaluate the process, then it's going to be very time consuming and very expensive.

What I do think would be a potentially useful compromise would be for some central agency (perhaps the ACGME) to act as a clearinghouse for LOR's for residents whom are terminated / let go. They could receive / hold the letters, and perhaps even review the content of the letters to ensure that they accurately reflect what happened in the prior program. In addition, it would ensure that the letter was at least complete. But, in the end, I don't know how much this would really help.

Alternatively, programs could be required to publish (or have published for them) the number of residents who do not complete the program. This is difficult also, as residents may leave a program willingly for a number of non-sinister reasons.

I disagree with the statement that a PD shouldn't be able to dismiss a resident. It's my job to ensure that my graduates are competent. If I have a resident who has proven unable to meet that standard, I need to dismiss them. Changing the broken system we have now for one that can't dismiss anyone is just as crazy.

First, no one in this world will make effect going through medical school, passing all the USMLE, going into residency training expect to be terminated over "incompetent or nontrainable", back to the base, we are all human.
My best friend is one of a few residents who was terminated. When you are a program director or an attending for PGY-1, you are the higher level in both experience/medical clinic skill, you are the leader. You should be able to take control over how much jobs are overload to a fresh PGY-1, how much expectation you want from this PGY-1, if the jobs is overload for one resident or you think he/she does not perform well compared to the others, give him/her some chance or time, at least time for him/her to adjust. If you think he/she not good enough to going to PGY-2 or PGY-3, offer him/her to repeat the fields that you think he/she did not do well. Remember, resident is a trainee not a physician yet. Once termination done, basically, the PD tells the whole residency programs that he/she is "not good or not trainable or not trustful " -- that is the result of termination leading to end a young potential doctor's career. He has been working hard to improve himself in both communication and medical knowlage, doing observership over years-- all these physicians who he shadowed wrote him very objective and good letters-- but none of these letters can overcome the " bad reputation" which was created from the evaluation letter ( LOR) from his previous PD. That is the real world out there. The action of termination and LOR from PD act like a blockage for him to get chance to get into residency training again.

 

[NotAProgDirector]

First, no one in this world will make effect going through medical school, passing all the USMLE, going into residency training expect to be terminated over "incompetent or nontrainable", back to the base, we are all human.

I'm not 100% certain what mean by this. If you mean that people who graduate from medical school and pass the USMLE must be competent to be residents, I disagree. If you mean that residents should somehow get another chance if terminated from one residency program, I would agree in some cases.

My best friend is one of a few residents who was terminated. When you are a program director or an attending for PGY-1, you are the higher level in both experience/medical clinic skill, you are the leader. You should be able to take control over how much jobs are overload to a fresh PGY-1, how much expectation you want from this PGY-1, if the jobs is overload for one resident or you think he/she does not perform well compared to the others, give him/her some chance or time, at least time for him/her to adjust.

Not exactly. If I hire you as a PGY-1, there is a certain level of performance I expect. Yes, I do not expect you to perform at the level of an attending. But, I do expect you to perform at the level of a beginning PGY-1. You you perform at the level of a 3rd year medical student, it is not my job to fix that. In that case, your prior training was insufficient.

If you think he/she not good enough to going to PGY-2 or PGY-3, offer him/her to repeat the fields that you think he/she did not do well. Remember, resident is a trainee not a physician yet.

Actually, residents are physicians, but let's not split hairs. I agree that a PGY-1 who is not ready to be promoted to a PGY-2 should be extended at the PGY-1 level IF they have made significant progress and are likely to promote to the PGY-2 in less than 6 months. If they are likely to take more than 6 months (and if so, who knows how long), then I don't think that continuing makes much sense.

Once termination done, basically, the PD tells the whole residency programs that he/she is "not good or not trainable or not trustful " -- that is the result of termination leading to end a young potential doctor's career. He has been working hard to improve himself in both communication and medical knowlage, doing observership over years-- all these physicians who he shadowed wrote him very objective and good letters-- but none of these letters can overcome the " bad reputation" which was created from the evaluation letter ( LOR) from his previous PD. That is the real world out there. The action of termination and LOR from PD act like a blockage for him to get chance to get into residency training again.

I agree this is a problem. PD's don't usually want to take a "risk" on residents. If a medical student fails out, it's "no big deal" for the school -- classes continue without interruption. If a resident fails out of a program, the schedule falls apart, everyone else has to cover shifts, and the PD has to try to find someone new (not an easy task). Hence, many PD's will, understandibly, shy away from residents who have failed out of a program unless they can be reasonably certain that the resident will perform better in a new program. There isn't an easy solution, as there is no way for anyone to work in a program "for free" or on a limited basis to prove themselves -- allowing that would allow amazing abuses in the system.

 

[residentdoctor]

I do not mean that all the graduates will be competent to be residents. My point is that if that person has the motivation go through all those educations and exams, that means that person has motivation and desire to be trained to a competent resident. lower level residents need to be trained by higher level residents or attendings. Sometimes, that PGY-1 ( low level) does not get what program expect him/her to do in next 2 minutes since there is not a very good standard/evaluation system set up by that PD in some programs and different high level attendings have their own habit/preference/order/personality to do things. A very good and dedicate PD/attending knows how to motivate and guide the lower level resident unless that resident just does not want to go through or physical/mentally not ready for the tough resident life. Of course if the resident makes a big mistake causing big medical problems- that is a different story.






That is true, if PGY-1 who is not ready to be promoted to be a PGY-2, there is should be time limited. There is should be time limited for any residents for improvement. I do not know the percentage of the terminated residents were actually gave some effective and clear improved period before the termination.

If you have access to the terminated letters, you will be shocked to see how negative common and evaluated report from PD toward the terminated resident. The reason why he/she was terminated must be written down on file or paper. Just like a person was sentenced to guilt at the court. I do not know how the other program will give a terminated resident second chance, other programs may think the terminated resident will not be able to make it through.

 

[ForbiddenComma]

I'm not 100% certain what mean by this. If you mean that people who graduate from medical school and pass the USMLE must be competent to be residents, I disagree. If you mean that residents should somehow get another chance if terminated from one residency program, I would agree in some cases.

The problem, which you alluded to, is that once a resident is terminated or forced out, their GME career is finished. As you know, modern PD doctrine holds that hunting out "red flags" is priority #1 for new applicants. Heck, judging by the journal articles I've reviewed, it is priority #1, #2, and #3, far more important than USMLEs or grades.

And the power of a PD over his or her residents, current and former, is absolute. You know this is true. If you elected to shower one of your residents with red flags simply because you didn't like him (and there is no bigger red flag than forcing them out), you know full well that their career would be finished. There is no check or counter to this power you hold over your residents.

They could get all the other LORs in the world from other attendings, including the chair or dean, but it would amount to a hill of beans because none of those LORs would be anointed with the holy inscription "Program Director." And without a positive reference from yourself, the resident is virtually unhireable. That's simply how our GME system is set up in this country.

I don't know you. I am sure you are a fair and kind PD who actually looks after your residents. I'm sure you don't play favorites. But if you did -- if you decided to pass incompetent residents because you liked them, and fire good residents because you did not like them -- you know that you could with little to no repercussions to yourself as long as your people at your school had your back. (And they would have your back. Who are they going to throw under the bus -- a veteran, well-respected PD, or some random intern? Right.)

My residency (peds program in Nevada) was the worst period of my life. I did well, I passed all my rotations and the inservice, but it didn't matter because the PD told me to my face that 1) he didn't like me, 2) people with Asperger's do not belong in clinical medicine, and 3) he would be searching during my entire 3 years of residency to find a way to fire me. Oh and besides my situation, 2 residents were fired over the past year, at least 2 held back, 1 voluntarily quit, a third of the entire program was placed on probation, all at the personal behest of the PD.

Is that a just and good thing that individual PD's such as this one have that much power over physicians in training, as opposed to a committee? Does that benefit GME physician education? Does it benefit future patients? You tell me.

 

[residentdoctor]

The problem, which you alluded to, is that once a resident is terminated or forced out, their GME career is finished. As you know, modern PD doctrine holds that hunting out "red flags" is priority #1 for new applicants. Heck, judging by the journal articles I've reviewed, it is priority #1, #2, and #3, far more important than USMLEs or grades.

And the power of a PD over his or her residents, current and former, is absolute. You know this is true. If you elected to shower one of your residents with red flags simply because you didn't like him (and there is no bigger red flag than forcing them out), you know full well that their career would be finished. There is no check or counter to this power you hold over your residents.

They could get all the other LORs in the world from other attendings, including the chair or dean, but it would amount to a hill of beans because none of those LORs would be anointed with the holy inscription "Program Director." And without a positive reference from yourself, the resident is virtually unhireable. That's simply how our GME system is set up in this country.

I don't know you. I am sure you are a fair and kind PD who actually looks after your residents. I'm sure you don't play favorites. But if you did -- if you decided to pass incompetent residents because you liked them, and fire good residents because you did not like them -- you know that you could with little to no repercussions to yourself as long as your people at your school had your back. (And they would have your back. Who are they going to throw under the bus -- a veteran, well-respected PD, or some random intern? Right.)

My residency (peds program in Nevada) was the worst period of my life. I did well, I passed all my rotations and the inservice, but it didn't matter because the PD told me to my face that 1) he didn't like me, 2) people with Asperger's do not belong in clinical medicine, and 3) he would be searching during my entire 3 years of residency to find a way to fire me. Oh and besides my situation, 2 residents were fired over the past year, at least 2 held back, 1 voluntarily quit, a third of the entire program was placed on probation, all at the personal behest of the PD.

Is that a just and good thing that individual PD's such as this one have that much power over physicians in training, as opposed to a committee? Does that benefit GME physician education? Does it benefit future patients? You tell me.

I can not agree with you more about that, the terminated resident was a " red flag" for any new program. The written reason were so nasty and not true to what he has been doing during at least 85% of his residency period. PD has such power who acts like the " god" to one individual ( the terminated resident). It is quite scared.

 

[NotAProgDirector]

Unfortunately, I have to agree with much of what you say.

Residency evaluation is a very subjective science. There is no test, evaluation, or procedure that I can do to tell if someone is competent or not. Taking a resident into a program who doesn't do well is a very bad event for a program -- it creates tons of schedule problems, stress, and bad karma for the program and the other residents. Therefore, most PD's will be very wary of taking someone with a history of problems.

Programs are already supposed to have committees to review resident performance. However, even if in place, such committees are completely dependent upon the data coming to them. So, even this is not an answer.

I can think of a couple of possibilities that could improve the situation:

1. When a resident is terminated, someone other than the PD has to review their performance and help put together a summary letter. This would presumably fall to the head of GME. This creates some safety/backup in the system, but in some places a PD is the head of GME also, or the head of GME might just take the report from the PD at face value.

2. The ACGME could require annual reporting from residents about the program director. This could include all terminated residents also. This would be easy to implement. Exactly what would be done with the data is unclear, but at a minimum it could be used in site visits. ACGME already does an annual resident survey, but the survey only includes currently enrolled residents -- if they surveyed graduates or terminated residents, it might be more helpful.

 

[ForbiddenComma]

2. The ACGME could require annual reporting from residents about the program director. This could include all terminated residents also. This would be easy to implement. Exactly what would be done with the data is unclear, but at a minimum it could be used in site visits. ACGME already does an annual resident survey, but the survey only includes currently enrolled residents -- if they surveyed graduates or terminated residents, it might be more helpful.

The ACGME already does this, but I don't think it has much power over malignant programs. My former program was absolutely savaged on the ACGME surveys by its residents, and the dean of GME was very upset at us for badmouthing the program to an outside entity, but nothing really came of it. I think the survey exists as a service to the programs, as opposed to something that could possibly trigger an investigation by the ACGME, an organization which does not seem to have much punitive authority over the country's GME institutions...

 

[zihuatanejo]

The ACGME already does this, but I don't think it has much power over malignant programs. My former program was absolutely savaged on the ACGME surveys by its residents, and the dean of GME was very upset at us for badmouthing the program to an outside entity, but nothing really came of it. I think the survey exists as a service to the programs, as opposed to something that could possibly trigger an investigation by the ACGME, an organization which does not seem to have much punitive authority over the country's GME institutions...

I agree that the ACGME is a worthless and toothless organization that merely serves a pulic relations purpose for GME programs. In fact it is worse than worthless and can be harmful to residents because any resident that complains to the ACGME does not get whistleblower protection and might be in danger of being targeted for retaliation by his program for daring to complain. Moreover, the ACGME has conveniently limited its enforcement options to either placing a program on probation or revoking its accreditation or doing nothing. Why would any resident want to shoot themselves in the foot by having his or her program lose its accreditation or get placed on probation? This would only harm that resident and other residents in his or her program.

I agree that ACGME surveys of terminated residents and residency graduates can yield more useful and honest information because those groups are no longer as beholden to the residency program even though they can still face retaliation from the program when applying to medical licensing boards or doing credentialing for hospital privileges or for joining insurance panels in the case of residency graduates or when applying to other residency programs in the case of terminated residents. However, such information from ACGME surveys will only become useful if it becomes public information that is accessible to everyone including medical students. That is a more effective way to hold malignant programs accountable for their actions and expose them for what they really are.

 

[residentdoctor]

I agree that the ACGME is a worthless and toothless organization that merely serves a pulic relations purpose for GME programs. In fact it is worse than worthless and can be harmful to residents because any resident that complains to the ACGME does not get whistleblower protection and might be in danger of being targeted for retaliation by his program for daring to complain. Moreover, the ACGME has conveniently limited its enforcement options to either placing a program on probation or revoking its accreditation or doing nothing. Why would any resident want to shoot themselves in the foot by having his or her program lose its accreditation or get placed on probation? This would only harm that resident and other residents in his or her program.

I agree that ACGME surveys of terminated residents and residency graduates can yield more useful and honest information because those groups are no longer as beholden to the residency program even though they can still face retaliation from the program when applying to medical licensing boards or doing credentialing for hospital privileges or for joining insurance panels in the case of residency graduates or when applying to other residency programs in the case of terminated residents. However, such information from ACGME surveys will only become useful if it becomes public information that is accessible to everyone including medical students. That is a more effective way to hold malignant programs accountable for their actions and expose them for what they really are.

That is exactly what happen-- facing retaliation. Even higher level residents were sometimes not willing to instruct lower level residents. The lower level residents are all stress out from exhausted work loads, not mention how many mistakens he/she ( the probation resident or the terminated resident) made according to the so call standard PD set up. if it is a major mistaken-- like affecting patient care, that is a different story. Lots of the time, the reasons for termination are so common even occurring in other residents who are the favor or the good resident in the eye of PD and program attendings, but they do not get into trouble. The PD really needs to do his/her job, very sincerely give effective/didactic/constructive correction period for the probation resident before terminating, those correction cases/paper works have to be written down, just like the USMLE -- all record in the systems.

 

[NotAProgDirector]

I'm not certain I would call the ACGME "toothless", but it's mandate is not what you are expecting. It's job is not to protect residents. It's job is to help programs. Resident surveys are a way to help programs, by giving them feedback from their residents. Ultimately the ACGME can remove a program's accreditation, but it hates to do so and really tries to let programs fix problems.

The ACGME never gets involved with a single resident issue.

"Whistleblower" status for residents is also a complicated problem. Programs clearly have to have the ability to weed out residents who are incompetent. If anytime I was in the process of terminating a resident for unsatisfactory performance they could "blow the whistle" on me and hence be "protected", that wouldn't work. That being said, I agree with you that the current setup is tilted too far towards the PD, so some adjustment is needed.

As far as giving residents some sort of remediation, I certainly agree for the most part. However, I have been involved in situations were a resident (usually not an IM resident, but someone from another field who is rotating in IM) arrives for work and is clearly not competent to be a PGY-1. It's usually obvious that the medical student is better than the intern. In cases like this, it's not my job to fix the problem. I can't remediate things you should have learned in medical school.

 

[zihuatanejo]

I'm not certain I would call the ACGME "toothless", but it's mandate is not what you are expecting. It's job is not to protect residents. It's job is to help programs. Resident surveys are a way to help programs, by giving them feedback from their residents. Ultimately the ACGME can remove a program's accreditation, but it hates to do so and really tries to let programs fix problems.

The ACGME never gets involved with a single resident issue.

"Whistleblower" status for residents is also a complicated problem. Programs clearly have to have the ability to weed out residents who are incompetent. If anytime I was in the process of terminating a resident for unsatisfactory performance they could "blow the whistle" on me and hence be "protected", that wouldn't work. That being said, I agree with you that the current setup is tilted too far towards the PD, so some adjustment is needed.

As far as giving residents some sort of remediation, I certainly agree for the most part. However, I have been involved in situations were a resident (usually not an IM resident, but someone from another field who is rotating in IM) arrives for work and is clearly not competent to be a PGY-1. It's usually obvious that the medical student is better than the intern. In cases like this, it's not my job to fix the problem. I can't remediate things you should have learned in medical school.

I guess we both agree that ACGME is indeed toothless when it comes to protecting residents. I guess the ACGME could remove all doubt by dropping all pretenses of caring about residents by getting rid of its ridiculous and meaningless resident complaint or concern process. This might give a naive resident the wrong impression that the ACGME cares about residents and their wellbeing. If as you are suggesting the ACGME's goal is to help residency programs improve themselves by providing them feedback from residents, why do some residency programs coach residents on how to answer the ACGME survey?

I also believe that you have completely distorted the real purpose of whistleblower protection in the work setting. The purpose is not to protect an incompetent employee from being terminated. The purpose is to allow employees to voice legitimate concerns about the practices of their employer without fear of retaliation. I believe that your conception of how whistleblower protection works is far-fetched. Can you please provide specific ideas of how you could responsibly close some of the enormous power differential between residents and program directors given the fact that you suggested that there was a need for that?

 

[ForbiddenComma]

Can you please provide specific ideas of how you could responsibly close some of the enormous power differential between residents and program directors given the fact that you suggested that there was a need for that?

I think it needs to be brought more in line with every other licensed profession out there.

In law, there isn't one single individual with the power of life-and-death over every new law school grad. If a given partner in your first firm doesn't like you, well, you can always get letters from someone else. There is no one person with one specific, universal title who fills out all the paperwork for a given lawyer's various state bar association memberships and who is always by far the #1 reference for a lawyer throughout his entire career.

It is just not right for one person with one specific title to have that much power. That sort of set-up will naturally attract malignant, nasty individuals who literally enjoy hurting people below them. (again -- not all or even most PDs are like this, please don't think I am generalizing to all individuals who hold that title)

I've worked in business and in journalism. There will always be nasty managers and nasty editors. But unlike in medicine, there isn't one person with all the power in the world. And even if you did get one loathsome malignant supervisor in business, law, etc who has made it their mission in life to force you out regardless of your job performance, all you have to do is not list them in your references when you apply for new jobs -- and, there isn't some sort of weird rule (like in medicine) where you are absolutely forbidden to talk ill of your last boss, no matter how much they relish talking ill of you.

There is nothing like this broken GME system in any other profession. Nothing even comes close, not even the military(!!).

 

[residentdoctor]

I think it needs to be brought more in line with every other licensed profession out there.

In law, there isn't one single individual with the power of life-and-death over every new law school grad. If a given partner in your first firm doesn't like you, well, you can always get letters from someone else. There is no one person with one specific, universal title who fills out all the paperwork for a given lawyer's various state bar association memberships and who is always by far the #1 reference for a lawyer throughout his entire career.

It is just not right for one person with one specific title to have that much power. That sort of set-up will naturally attract malignant, nasty individuals who literally enjoy hurting people below them. (again -- not all or even most PDs are like this, please don't think I am generalizing to all individuals who hold that title)

I've worked in business and in journalism. There will always be nasty managers and nasty editors. But unlike in medicine, there isn't one person with all the power in the world. And even if you did get one loathsome malignant supervisor in business, law, etc who has made it their mission in life to force you out regardless of your job performance, all you have to do is not list them in your references when you apply for new jobs -- and, there isn't some sort of weird rule (like in medicine) where you are absolutely forbidden to talk ill of your last boss, no matter how much they relish talking ill of you.

There is nothing like this broken GME system in any other profession. Nothing even comes close, not even the military(!!).

Relish talking ill of the terminated resident in the papers-- that paper is the requirement to apply for other program. More some PD and some programs won't allow other individual attending whom the terminated resident worked with and did do a decent job to write any letter to say nice things about the terminated resident or even a few objective things regarding his/her performance.

 

[ForbiddenComma]

Relish talking ill of the terminated resident in the papers-- that paper is the requirement to apply for other program. More some PD and some programs won't allow other individual attending whom the terminated resident worked with and did do a decent job to write any letter to say nice things about the terminated resident or even a few objective things regarding his/her performance.

Some individual attendings still will write you an LOR if you approach them before the PD does. But you are correct in guessing that if the PD approaches them first, they won't help you. It comes back to the same calculus employed by the dean of GME and the residency committee: who are they going to side with, a powerful veteran PD or some random resident?

I was fortunate enough to get some letters before the PD started reaching out to everyone, because I saw the writing on the wall as early as the October of my intern year. (My PD at my peds program in Nevada, to his credit I suppose, was very honest and forthcoming about his intention to find any means necessary to terminate me due to my having Asperger's.)

But for residents who get sandbagged and can't reach out to anyone before the PD does, this is another major problem. It all goes back to the problem of one singular person having all the authority in the world.

 

[residentdoctor]

Some individual attendings still will write you an LOR if you approach them before the PD does. But you are correct in guessing that if the PD approaches them first, they won't help you. It comes back to the same calculus employed by the dean of GME and the residency committee: who are they going to side with, a powerful veteran PD or some random resident?

I was fortunate enough to get some letters before the PD started reaching out to everyone, because I saw the writing on the wall as early as the October of my intern year. (My PD at my peds program in Nevada, to his credit I suppose, was very honest and forthcoming about his intention to find any means necessary to terminate me due to my having Asperger's.)

But for residents who get sandbagged and can't reach out to anyone before the PD does, this is another major problem. It all goes back to the problem of one singular person having all the authority in the world.

He already approached to the attendings whom he worked with, but the PD/program asked the attendings not to do so.

 

[ForbiddenComma]

Thinking about this problem more, something occured to me:

Why do we need to care about program directors or their residencies at all?

And the answer to that is simple: The American Board of Medical Specialties. http://www.abms.org/ They are private. They are unelected. They answer to nobody. And they set the rules that govern everything else behind our GME system.

We all know this, and yet we never discuss it.

They require years of underpaid service in APPROVED programs only in order to be BC/BE in a given field. It's not like law or business where you "specialize" in a field simply by putting hours in at a private firm -- or on your own. You must "match" into a business entity which, as we all know, will pay you less than minimum wage for long hours of work while dangling the one carrot of "Board Eligibilty" in front of you, while you must try to ignore the Sword of Damocles that might drop down at any time should you fall out of personal favor with the one person anoited with the title of Program Director.

Because of this system, intentionally set up by the American Board of Specialty as well as their clients at the ACGME, we are at the mercy of a singular Program Director for our 3-5 years of residency, a person who can end our careers with a snap of his fingers with zero repercussions to himself

A lawyer does not have to put in 3 years in a Family Law residency to become a divorce lawyer, during which time his career can be ended (or saved, in the case of incompetency, which is a far worse crime) at any time on the sole whim of his Program Director. A businesswoman does not have to put in 4 years in a Stock Exchange residency to become a stock broker. A CPA does not have to put in 5 years in a Corporate Accounting residency to become a corporate accountant. All of these examples are insane on their face.

The root of the problem is the ABMS. We should not blame the ACGME -- as we all know, they are a toothless client organization. If we could sit for written and oral board exams without having to jump through insane hoops set by this private, unelected, non-government agency first, the problem would remedy itself. People could choose to work in private practice to avoid malignant PDs, which would rob the same malignant PDs of their power overnight. And medicine would be brought back in line with every other educated profession such as law and engineering.

Why can't this be done?

(edit: the one saving grace for many people is that our nation's laws have not caught up to the ABMS's vision of medical education. States still do not require ABMS board certification in one of their 24 specialties to become licensed. This is a relic of the past, pre-1970s, when most docs did not even go through more than 1 year of residency, but it allows a way for docs to still put food on their table despite their PD's wishes.)