As a relatively young attending, I have yet to be involved with or hear about a program for which remediation was done as extra time. In my experience, adding time to residency and letting someone graduate "off-cycle" is reserved for people who have been physically absent for various reasons- illness, a family catastrophe, and so on. Meanwhile, remediation is done by adding more oversight/requirements within the time the resident already has to complete. You might change the rotation schedule so the resident is put back on a rotation they struggled with, or on a rotation that carries less responsibility, but I've never heard of time being added to somebody's years of residency. Even if time was added, that would mean an extra body in the call schedule, which would make things easier on the program. Meanwhile losing a resident from the rotation/call schedule (at least in my field) is nothing short of catastrophic. So the argument that remediation is as hard on the program as simply kicking them out does not ring true for me.
It may be that things are different for other specialties that have larger residency classes, which may be where you are getting your impressions.
Let's just say I have it on *very* good authority that extension of training time is in fact one avenue for remediation, if it's appropriate and feasible. There are also numerous posts on here from previously terminated/resigned residents who mention having their training extended (and even serving the extension, meaning it was not just theory but was done) as remediation before getting the final boot.
I also found the verbatim quote I kept from someone who professed to be a bona fide program director confessing the following:
"Additionally, their funding is only good for 3 years. If they are not competent at the end of that time, the cost of any additional training is eaten by the program. Some programs will thus terminate underperforming residents that may eventually become competent physicians with enough time, rather than continue attempts to remediate at a significant cost to their program."
I do not want to overrepresent this quote. I googled it and did not find its match. I think I picked it up from a Dr. Pamela Wible physician suicide article (or other resident sweatshop related article) on medscape from the comments section which was like 200+ long and wouldn't come up on google because you have to be logged in with an account to see those. Otherwise the only other source that would come to mind would be SDN, but I would have expected it to come up. I'm fairly certain this is referring to an IM program with the 3 year preference and what I remember of what I read.
You do not have to believe me or the quote, but if you believe me, what I can tell you is that I copied and saved this quote to my hard drive verbatim when I came across it because it purportedly was a direct posting from a PD, and let's just say there are people I know who felt their experience to be very vindicated seeing this quote, which is why I preserved it.
So, when I combine what I know for a fact is true, which is that residency extension can be done for remediation and *not* only for otherwise legitimate absences, I certainly find it believable with the facts of funding etc. that some residents are terminated for just being too slow in progress. So if they go to another program and start over and are successful, that right there is giving them more training time and may support that people just weren't happy with pace of their work and got them gone and after getting more training time now they are fine.
We don't want to believe that *sometimes* (maybe more than we might want to think even) residencies just cut and destroy slow residents who could be great docs given a little more training time because our training system is that rigid. I have talked with PDs and I know they don't want to cut a slow resident that just needs more time, but I know that they do sometimes. The system isn't well designed for that. I didn't save the post, but in this same discussion someone who trained in India said that there, once someone graduates medical school and enters training, they are able to continue in that training as long as they are considered remediatable (for the purposes of this argument, that they just need more time).
It shouldn't be that hard to believe. MD grads come out very unevenly, and I would love to find these Perrotfish posts about how different residencies can have vastly different workloads waiting for the intern day 1 (1 senior 1 intern 10 patients vs 1 senior 1 junior 2 interns +/- med student 20 pts, big difference, more like 5-7 for intern at first, a less hellish step from 3-4 they had as med students), and if the two wrong extremes meet, then you have an intern that's drowning and it was a systems issue. Then you can now add the label of problem resident, constant criticism over your shoulder, and see how that helps. And it's not a lie here that programs will say "remediate" and even draw up a PIP with VERY specific terms, not only for the resident, but themselves. And then they don't follow through because no one has time. But they set up the paperwork to show they tried and now they can make a case to terminate.
If training time alone was not a huge factor in training and determinant of level of competence of graduates than programs would not be so obsessed with cramming as many work hours in a day in a week into as short a time as possible and saying that was why. Unless it really is a ponzi scheme to milk residents for hours. I will legitimately buy into that all those hours, and then some, are needed. I get it, I'm all for training residents as fast as possible, and that there's value in this sort of immersive exposure approach to training. But if we're making the argument that we're hardly getting the training hours we need as it is for all the residents we're putting out there as attendings, the 98% who graduate in this time frame, then is it crazy to think that there could be a solid proportion of the 2% that represent an upper end of a bell curve of hours needed to train to be competent? They were just slow and otherwise unliked residents that needed some more time to get it together?
The only way to chalk it up to system and not just fault of resident is to give them more training time or other remediation and see what happens. This does happen.
So in line with the comment I had ripped verbatim, and now wish I had taken time to copy as well, was that an attending from India said that this system was ridiculous, because in India anyone who sucessfully gets their MD, qualifies for post grad training, is able to stay and train as long as they are remediatable, ie is safe with supervision and making progress and otherwise not a *******. Usually that is 3 years but could be up to 5. But in their system they do not have the same malpractice and other administrative costs, and even an IM resident stuck at the PGY2 level for let's say 2 years is still considered a value added to the system, and funding and slots not limited the same way as here (of course, one can argue that sure maybe $ isn't the issue, but is there enough quality slots, ie have good enough clinical cases/exposure in the slot?). In any case, they feel that someone who was successful in getting an MD and the only real issue is needing another year or two in the hospital under supervision, is well worth the investment than just throwing that MD's potential to be a doc away. You're saving one or two years in training and potentially losing 40 years of good practice.
We are one of the only countries that would create a situation where a resident must progress through each PGY at the same pace or else is just not fit to continue to train, and giant Scarlett letters are handed out for it. I forgot to mention, in deference to the programs, given the short number of years, and funding involved, and how things trickle down, they often don't have the resources to hold out very long to give much time to a struggling resident to see where they end up. They save time and money to cut them early on after a short remediation period and start over, rather than potentially wasting more time money resources staffing coverage on someone that doesn't improve with time, or improve at the rate needed, and have that trickle through the rest of the training time. This is some basic economics I'm describing at this point.
I've read also about what other countries do towards remediation.
We like to think we have the best system for training MDs, and maybe it is the most ruthlessly efficient, but I think there's some wheat being tossed with the chaff.
Food for thought.
I know there's some dangerous a*holes getting tossed, people in the wrong specialty, people not well suited, idiots. But I also think there are some diamonds in the rough, and I think those people deserve to at least be recognized rather than this denial of the idea that there exists enough dysfunction in the system to create such a scenario.
Better that 10 guilty men go free than 1 innocent man be damned. I'm not saying let's keep bad residents around, but if you are the one good in the ten, numbers alone don't minimize the tragedy of individual injustice and suffering (if we think residents who just need more time and don't get it and don't get to practice is an injustice, to them, to society.)
In the case of medicine, better to let 10 good residents go than keep 1 bad would be more like it. Dangerous people kill people. Fine.
I still think there's some very unlucky residents out there, and the rarity doesn't make it any less sucky or worthy of treatment. Call me a champion of orphan diseases.
