Non-Renewal

[drumandmonkey]

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I am a PGY-2 resident at a top 10 program in the nation. I got a contract non-renewal this year after failing remediation. I have been looking for other residencies since February when it became apparent that I was being let go. I do not wish to delve into the reasons for poor clinical performance, just suffice it to say that there were no professionalism or academic issues (in-training was ahead of class average, no problems in medical school or intern year). I think the program I was at was very intense and I burned out and just could not improve my performance without a break. I am on okay terms with the program admin and the PD agreed to recommend me for other IM programs.

My problem is that I am having trouble finding programs that will give me a chance. This is frustrating, because programs that tend to have vacancies are also intense programs, and for some reason (despite promises made by PD to recommend me to these specific programs), all interest vanishes once the programs call the PD.

I am using the time until end of this semester to really rest up and read about problems that I encountered, including working on weak areas. But I really need to get back into training or at least get a clinical ward opportunity pretty quickly or what skill I have would rust. I have a medical license but hospitals won't hire me even for supervised non-residency ward positions since I am not board-eligible. I will do insurance physicals to stay afloat if I have to, but I want to do inpatient medicine, because that is the bulk of residency. I do care a lot about the program that I train in, because I do not believe that "bad" programs actually are easier to get through, and the training is poor so that you will be ill-equipped for the future. Ideally I want a top 30 program, but even if I go top 50 I still find myself being rejected. This is disheartening and frustrating.

Any ideas on the best course of action - keep putting myself out there with programs that I would be interested in and maybe there is a PD who is willing to give me a chance should another vacancy pop up? Ask to repeat intern year after a new PGY-1 fails to show up? Go for any program, even the community ones that apparently routinely flunk IMGs?

Thanks for the advice.

 

[ThoracicGuy]

You are in a tough position. If that call to your PD turns programs away, its going to be hard to get a new position. Are they going to give you credit for 2 years? You should look for PGY1 and 2 spots anywhere. You don't have the luxury of being picky anymore, even if it means an IMG sweatshop...

 

[jdh71]

Two things here by my spidey sense. 1) you are either downplaying your problems or your problem is the kind of thing that will continue at the kind of programs you are shopping yourself too. And 2) you are trying to find a spot much too high in the academic hierarchy - you need to expand your search. If you continue to think certain programs are "beneath" a guy who didn't have his contract renewed you are smoking weed.

You need to decide what you want. To fish residency or spend the rest of your days doing insurance physicals. Maybe working in urgebt care.

 

[drumandmonkey]

Thanks for the advice. I am wondering what are the chances that a PGY-1 spot will open up when it comes time to start? What are the chances that an intern will fail to show up?

 

[jdh71]

Thanks for the advice. I am wondering what are the chances that a PGY-1 spot will open up when it comes time to start? What are the chances that an intern will fail to show up?

Extremely low. Almost everyone shows up day 1.

 

[drumandmonkey]

I am also interested in working on a hospitalist service while I look around more. I would be working in the capacity of a mid-level, while I continue to look for residency positions. Is this possible?

 

[jdh71]

I am also interested in working on a hospitalist service while I look around more. I would be working in the capacity of a mid-level, while I continue to look for residency positions. Is this possible?

No.

 

[drumandmonkey]

Why not? Do PAs and MDs cost differently to hire? Are there legal issues with this?

 

[Instatewaiter]

Pa's and nps can bill. You cannot. Furthermore since you are not in a training program the attending who would be overseeing you could not use the billing modifier for a training program that bills more.

 

[jdh71]

Why not? Do PAs and MDs cost differently to hire? Are there legal issues with this?

You're not trained to do that kind of job. And while it's somewhat theoretically possible no one is going to go for that kind of arrangement even if you have a license. Actually especially because you have a license. Outside of training one doc working under another doc doesn't make sense and causes difficulties with billing. Not to mention liability problems.

 

[sluggs]

If I were you, I would shotgun applications and scour residency program swap/opening boards. Can you get any credit for "time served" at your first place?

 

[ArkansasMed]

Yeah I would have to agree with everything said above. I would hope for any spot available at this time and make sure to not let what happened at your old program transfer over.

 

[Crayola227]

You need to get your priorities straight
Especially as an IMG
Are you smoking crack? you're looking to get your career out of the gutter where it currently is lying dying a slow death

1) were you trying to position to get fellowship? I don't know what non-renewal does to your chances, but I bet even if you went to "top 30" "top 50" your chances are still ****

2) so now that we've figured out that your least concern right now is fellowship, but simply finishing residency, let's begin

3) if you are on good enough terms, in a nice way, sit down with your PD and tell him that the places that were interested in you seemed to lose interest. does he have any ideas why? is there anything you can do to address it? does he have insight if it is a program specific issue or ways that you are not a match for those programs? you would like help trying to find appropriate programs

if it becomes clear from this conversation that there is something he is telling them and not you, nicely ask your PD if there are concerns he has about recommending you to these programs, and what they are. tell him you do not expect him to alter his opinion, you just want to know what they are so that you can consider how to remediate them, or, if not these are things he does not feel are remediable, you want to know what your weaknesses are regardless, because while you want to go into IM, it's more important that what you do in medicine plays to your skillset and lets you be successful in caring for patients. It doesn't matter to me if you mean that last sentence, logically it should matter to you, but in any case this is the only way you can demonstrate maturity to your PD and try to pry from him if there is any **** he talking about you so you can try to strategize, and also it's good to have an objective honest appraisal of your skills, ultimately it is up to you to have the necessary insight to know/admit to yourself what he identifies as being true about you, distorted, and in any case it you are able to address those thing or not, or have to accept that those are just your weaknesses
this convo with your PD may or may not end up being helpful at all

likely whatever negative things were said about you as reasons for remediation and non-contract renewal, and in evals, are what are being said if the PD doesn't say what exactly he's saying
it would do you well to acknowledge those things to him in a diplomatic manner, and tell him what you are doing in the interim to address them, and how much you would appreciate a second chance somewhere and what you would do differently there if given the chance
So, the last bit of advice I gave you about acknowledging stuff, even if you don't believe it (and you really should consider it), is what you are expected to do with whatever program that considers taking you on, so it only makes sense to go over this with your PD, because the new program will only believe it if you old PD believes it, capice? any insight into what your old PD's story is can help you make your personal statement and any interviews consistent with it in a positive way

4) next most important thing for your strategy: are you getting credit and how much? if you have credit for PGY 1 and PGY 2, then you are doing yourself a favor to try to find PGY 3. Some people who only have credit for PGY 1, +/- if there's anything PD will sign off on for PGY2.

5) I would apply to every single f*ing PGY2 (if you didn't get credit for that year) spot that I thought I could successfully complete, you will likely only get one more shot at finishing your residency, so rather than worry about quality of training, rigorousness, or cushiness, you just need to know if 1) will they take you 2) if they take you will you complete it. you're worse off taking a sweatshop spot where you're doomed to fail for whatever reason (the system, it's malignant, design will only magnify weaknesses, etc) because you cannot afford to fail again. better to be benched right now than swing and miss. you also have to wonder WHY they have an opening, does this program run people off or is not good at remediation or was it a luck of the draw kind of thing (last guy was a rapist, died, decided they wanted different specialty, program just picked the wrong person/bad fit) you're not necessarily in a position to get the answers to these questions, I'm just driving home that YOU NEED TO BE WILLING TO GO ANYWHERE PROVIDED YOU THINK YOU CAN MAKE IT STICK. That's the only caveat. Only because failure again is not an option, that should be the only standard you're applying, so I'm not saying take anything that comes your way or don't be thoughtful, but that your only thought is finishing

6) if you only have credit for PGY 1 +/- partial credit on PGY 2, and the above is not panning out as far as more advanced positions, some people will go through the match again for PGY 1

7) Look for vacancies outside the match as listed on residentswap and the other official site where that's posted, don't know where

8) Fall back plan for a first year slot is also after scramble and maybe a bit around June emailing every program you think might consider you and let them know that you are looking for a position, so if any unexpected vacancies come up....

9) others can chime in here if they know better the details of when, but also if you're looking for spots there are certain times of year where programs experience vacancies, PGY1 there like a mid-year sweet spot where people say f8ck IM or the program cuts them, there's also a sceond time which is later on which has to do with contract renewal decisions

10) strategize about weaknesses, what you can say about them , and time fillers for now which will keep you in the game and look good, especially ones you can spin into how you're addressing weaknesses/demonstrating that prior problems are getting attention through these activities

11) worry about getting the best spot you can (yes, it's OK to try to get the best spot you can, but beggars aren't choosers cast a wide net, and "best" spot is the one that is the most *workable* *finishable*, and if it's somewhere you graduate from but still feel incompetent, whatever, you can fix that later believe it or not. there are places where you can be a "house physician" to get more supervision and practice, there are a few very few "get back to clinical practice after years away" intensive workshops that may not be a perfect fit but can give you ideas on getting more hands-on observorship stuff, point is, worry about getting to attending, not quality right now, once you get there, if you're really worried there are ways to do clinical medicine and address weaknesses as attending, some people take a big paycut in exchange for being a junior partner under a more senior partner's wing in a group practice and stuff like that

 

[Crayola227]

Why not? Do PAs and MDs cost differently to hire? Are there legal issues with this?

The other thing to keep in mind is that in the world, the initials "MD" is like a target on your back for lawsuits. Even without a license.

With that MD, they wouldn't even hire you to be the receptionist, because if someone ran in from the parking lot huffing and puffing and falls dead in front of the front desk where you are sitting, you are infinitely more sue-able than anyone else in that chair

 

[Crayola227]

and given my other post, I feel like an a*hole now

I get it, your dream has been crushed cruelly and capriciously
you went from top 10 positioned for fellowship and to live exactly the live you wanted and worked for all this time

if I used hyperbole about putting this back together, it is because I want you to have the best second crack at this you can and make it stick

Godspeed

 

[JP2740]

How do you go to a top 10 program and get non renewed because of something that's not a professional issue? Legit Q, scares me

 

[Crayola227]

How do you go to a top 10 program and get non renewed because of something that's not a professional issue? Legit Q, scares me

Depends on what you mean by professional issue.

You can look at posts I've made and see the horror stories. More importantly, I point out all of the things to do/avoid to not end up a statistic. Playing it safe. That's what docs do, right? I'd like to help.

In fact, I may need to gather my posts into a blog for the
Prudently paranoid persecuted intern (TM) - because it's not paranoia if they really are all out to get you

https://hbr.org/2002/07/when-paranoia-makes-sense

unabashedly taken from Wikipedia article on distrust:

"Distrust has also been shown to increase the speed and performance of individuals and groups[2] at certain tasks. One way to classify tasks is to split them into routine (normal, usual) and nonroutine (creative, unusual, undefined). In experiments distrust has been shown to increase performance in nonroutine tasks while decreasing performance in routine tasks.[3]

Research on high risk settings such as oil platforms, investment banking, medical surgery, aircraft piloting and nuclear powerplants has related distrust to failure avoidance.[4] [5]When non-routine strategies are needed, distrusting persons perform better, while when routine strategies are needed trusting persons perform better.[6] This research was extended to entrepreneurial firms by Gudmundsson and Lechner.[7] They argued that in entrepreneurial firms the threat of failure is ever present resembling non-routine situations in high risk settings. They found that the firms of distrusting entrepreneurs were more likely to survive than the firms of optimistic or overconfident entrepreneurs. The reasons were that distrusting entrepreneurs would emphasize failure avoidance through sensible task selection, and more analysis.[8] Kets de Vries has pointed out that distrusting entrepreneurs are more alert about their external environment.[9] Thus, distrusting entrepreneurs are less likely to discount negative events, and are more likely to engage control mechanisms.[10][11][12][13] Thus, according to Gudmundsson and Lechner distrust leads to higher precaution and therefore increases chances of entrepreneurial firm survival.[14]