Not being promoted to PGY-3-Need Advice!

[Tipu]

My wife is a PGY-2 Internal Medicine resident. She failed her Step 3, but retook the exam and passed it before her PGY-2 year ended. However, her hospital policy was that if she didn't pass the exam by the Jan 31 deadline, she will not be promoted to PGY-3. She got her results from the 2nd try in April and passed. Her program director gave her a two month extension until August to evaluate her progress. Last week, she was told that she will not be given a contract extension, and that she is basically being removed from the program, in other words fired.

We are both really confused as to why this happenned. She got good evaluations from her attendings except for one, who gave her a marginal evaluation. But he is known to given tough evaluations to all residents so this was not surprising. We both now wished the program director hadn't given her the two month extension as we then we could have applied to other programs before the July 1st date.

Now we are at a loss at what to do? All programs have already filled thier open PGY-3 spots, and just a handful of PGY-2 spots are available. Also, someone told us that since she already got paid for PGY-2, she will not get paid for it again if she goes back somewhere as PGY-2.

Can someone please advise us on how to proceed.

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[dragonfly99]

Wow. Sorry about your wife's troubles. That is a hard situation to be in.
I think that she should seek more information/input from the program director about what is the reason for her being fired. Was it just the failing exam score and that 1 evaluation? Were there more concerns that weren't really being brought up to her, or she didn't realize these were big concerns, so she didn't get that she was one step fro being fired.

It kind of doesn't matter at this point whether she agrees with the negative evaluations or not...IMHO when you are a resident you have very little power. I guess she could get a lawyer and try to "force" them to take her back, but I think what is the point of being in a program where they don't want you, and are likely to be "laying for you"? I guess if I were in that situation I would try to meet with the program director, don't get overly upset whatever he says. Try to find out why I was fired, what were the specific concerns. Then I would just ask to get a neutral letter of recommendation from him (do not waive her right to see this, but get a copy). If you see the letter and it is really bad, then consider getting a lawyer...perhaps you could twist the PD's arm into making it more noncontroversial/neutral, but I'd try the nice approach first. Then I would find all the faculty who liked me and try to get a couple of letters of recommendation from those people, and then try to switch to another residency program (same vs. other specialty, depending on what specialty she is in). If she's in some competitive specialty like a surgical subspecialty, she might be screwed in terms of getting in to a different program of the same specialty, but I'm sure she could use her skills in another way.

 

[Winged Scapula]

I agree with dragon...that sounds strange. Programs don't generally fire someone for one bad evaluation. As a matter of fact, according to ACGME, programs are required to have documented evaluation sessions with each resident and that the resident understands if there are any concerns and what plans are made for remediation. As dragon notes, either she was told that and didn't understand the significance or her program has violated this. Most programs are exceedingly careful about documenting these concerns, however trivial they may seem to the resident, because they can and have been sued for firing a resident. So it seems strange to me that she would have "only one bad evaluation" and that other problems have not been documented. Perhaps the two month extension was simply a way to get rid of her for the simple fact that it may be that her program requires passing Step 3 by a certain date (which is sounds like she did not)...some rules can be broken if you are well liked, and others cannot.

Here is the link to the program requirements for IM:http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_im_07012007.pdf


Therefore, she should get copies of all her records, evaluations, etc. used to make the decision to fire her. Suing is an option, but as noted in the response above, generally does not work out favorably for anyone involved...after all, she makes herself a pariah at this program and pretty much everywhere else she goes because from now and forever after, this PD will be required to fill out forms on her whenever she wants hospital privileges, to join a group, etc. Pissing someone like this off is generally tantamount to career suicide.


Most programs are required to give you 120 days notice of a contract non-renewal: http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf.

This is why contracts go out in March/April for the following July. When you say that she got a "two month extension" do you mean that she was not offered a contract for the entire PGY-3 year back this spring and only signed a contract for two months? Unfortunately, that should have been the handwriting on the wall to her. This is exceedingly unusual and should have indicated to her that she would be fired soon. Programs can put you on probation or ask you to complete remedial coursework but when they decide only to offer you a two month contract, that is generally an ominous sign (heck, it is in most workplaces). If she signed a full year contract, then they have to give her 4 months warning of non-renewal, which means she could technically stay until the end of the year and finish, but it sounds as if that was not the case.

But you have a bigger/additional problem than just finding a PGY-3 position. It is my understand that you have to finish the last two years of an IM residency in the SAME program; therefore, she is not eligible for a PGY-3, but only a PGY-2.

At any rate, she needs to do some damage control now - get letters from the faculty who supported her, copies of everything in her file, and to further discuss this with the PD because it sounds fishy - either she isn't telling the full story, doesn't understand the full story, or the program is hiding something. Programs just don't fire good residents whom they like.

So I suspect that they had concerns about her already and when she didn't pass Step 3 the first time, they stepped back and reevaluated and decided they needed to do something to fire her. The two month extension I suspect, as I said above, was simply a way of getting out of keeping her on, or perhaps there was some tiny shred of hope on their part that she would get better.

I'm sorry this happened--unfortunately, it is not uncommon and residents really have little power in this game. I suggest she get the references she needs and starts looking for a PGY-2 position.

 

[Tipu]

Thanks for all the advice. I will make sure my wife reads it as well.

The program director seems to pretty much follow the rules as written without any exceptions, so when my wife missed the deadline of Jan 31 to pass her Step 3, that was supposed to be it for her. However, nearly all the attendings were very supportive of her, and convinced the program director to at least give her a second chance, which she did in the form of an extension. Most people at the hospital including us believed at that point the extension was merely a formality and she will be able to sign her 3rd year contract this month at the end of the extension.

I'll have my wife post other details.

 

[PalmOlive]

My wife is a PGY-2 Internal Medicine resident. She failed her Step 3, but retook the exam and passed it before her PGY-2 year ended. However, her hospital policy was that if she didn't pass the exam by the Jan 31 deadline, she will not be promoted to PGY-3. She got her results from the 2nd try in April and passed. Her program director gave her a two month extension until August to evaluate her progress. Last week, she was told that she will not be given a contract extension, and that she is basically being removed from the program, in other words fired.

We are both really confused as to why this happenned. She got good evaluations from her attendings except for one, who gave her a marginal evaluation. But he is known to given tough evaluations to all residents so this was not surprising. We both now wished the program director hadn't given her the two month extension as we then we could have applied to other programs before the July 1st date.

Now we are at a loss at what to do? All programs have already filled thier open PGY-3 spots, and just a handful of PGY-2 spots are available. Also, someone told us that since she already got paid for PGY-2, she will not get paid for it again if she goes back somewhere as PGY-2.

Can someone please advise us on how to proceed.

Can you say which residency program this is or at least what field and what part of the country?

 

[radslooking]

please do not post what specific residency program this is. i think that would be a bad idea for everyone involved.

 

[dragonfly99]

Do NOT post the program name here, or any details.
That would just be asking for trouble for your wife.
I'd just be movin' on down the road if this were me. You know, I've never had problems with standardized tests, but I think it's kind of weird that programs make people pass Step 3 to go to 3rd year. I don't think my program even had a rule about when you had to take it. I know I didn't take mine by 1/1 of my 2nd year...I took it whenever the heck I wanted to, which I think was the tail end of 2nd year. Only people who were dying to moonlight bothered to take it early. I know a lot of surgery programs make people take it in order to advance to 3rd year, and some will fire you if you don't pass.

If I were this person, I'd get the most positive letters of rec. that she can, then extract a promise from the PD to write as nondamaging letter of evaluation as he is willing to do. Then I'd make sure I see the letter. Then I'd get the attendings that liked me to call some people they know at other programs, and see if there is any way at all to get in to another medicine program. And during the interviews, I'd just spin this as "I know I made a mistake and maybe I'm not a great test taker, but...". Nobody cares that you were done wrong, or think you were done wrong. I think there are many places that would forgive an isolated low test score, but if they think she is malignant and/or lazy, nobody will hire your wife.

 

[elwademd]

Do NOT post the program name here, or any details.
That would just be asking for trouble for your wife.
I'd just be movin' on down the road if this were me. You know, I've never had problems with standardized tests, but I think it's kind of weird that programs make people pass Step 3 to go to 3rd year. I don't think my program even had a rule about when you had to take it. I know I didn't take mine by 1/1 of my 2nd year...I took it whenever the heck I wanted to, which I think was the tail end of 2nd year. Only people who were dying to moonlight bothered to take it early. I know a lot of surgery programs make people take it in order to advance to 3rd year, and some will fire you if you don't pass.

If I were this person, I'd get the most positive letters of rec. that she can, then extract a promise from the PD to write as nondamaging letter of evaluation as he is willing to do. Then I'd make sure I see the letter. Then I'd get the attendings that liked me to call some people they know at other programs, and see if there is any way at all to get in to another medicine program. And during the interviews, I'd just spin this as "I know I made a mistake and maybe I'm not a great test taker, but...". Nobody cares that you were done wrong, or think you were done wrong. I think there are many places that would forgive an isolated low test score, but if they think she is malignant and/or lazy, nobody will hire your wife.

some programs do not make it a choice, but rather it is a state law that must be enforced.

california for example states that a resident must be licensed by the beginning of their 25th month of training (36th if fmg/img)... and in order to be licensed, you must have taken and passed step 3... and given that paperwork takes time, you really need to have done it at the latest 2-3 months before that hard deadline.

so, if you start residency july 1... you need to be licensed by june 30th of your 2nd year... which means have passed step 3 by march at the latest. (personally, i took step 3 in april of my intern year, and received my ca medical license in september).


tipu, at the end of the day, the rules are the rules. honestly, i would tell your wife just to move on.

what's most important to know is if she satisfactorily completed her pgy 1 year as well as her pgy 2 year. provided both are satisfactory, she needs to look for a pgy 3 position. if the pgy 2 is marginal, she may need to look at a pgy 2 position. and i know there may be issues about funding, but in internal medicine, a resident getting a marginal in the pgy 2 year as well as not passing step 3 in that same year, some remediation (in form of repeating the pgy 2 year) may be good for her in the long run.

 

[3dtp]

some programs do not make it a choice, but rather it is a state law that must be enforced.
...
what's most important to know is if she satisfactorily completed her pgy 1 year as well as her pgy 2 year. provided both are satisfactory, she needs to look for a pgy 3 position. if the pgy 2 is marginal, she may need to look at a pgy 2 position. and i know there may be issues about funding, but in internal medicine, a resident getting a marginal in the pgy 2 year as well as not passing step 3 in that same year, some remediation (in form of repeating the pgy 2 year) may be good for her in the long run.

I think Winged is right on this. IM requires the final two years to be in the same program. It looks like she'll have to complete two more years, irrespective of the marginal/pass status of PGY2. A marginal status of PGY2 is, I think converted to a pass upon successful completion of PGY3. Go to the ABIM for words of wisdom. They are the ultimate authority.

 

[NotAProgDirector]

It turns out that there is not an ABIM rule that requires the last two years to be completed at the same program. This is a rule for ABFP board certification.

However, even though there is no rule about this, I think the OP will find that getting a PGY-3 spot after being dismissed from a PGY-2 will be very difficult. Most programs expect their PGY-3 residents to function with very limited supervision -- they are often given roles where they are the "backup" to everyone else -- ie. running an ICU, or being a "senior in house", or something like that. The PGY-3 year is also usually more elective heavy, and has less call blocks.

So, if someone doesn't progress in their PGY-2 in their program, it's unlikely a new program will simply give them a PGY-3 spot.

The good news is that you wouldn't need to complete a full PGY-2. You could negotiate with a program to take you as a PGY-2 for 6 months. If your performance is satisfactory, then they can promote you to a PGY-3. If it's not, then they can continue you at a PGY-2 level, or terminate you. That's about the best you can expect at this point, short of repeating the entire PGY-2.

Note that the ABIM requires 36 months of training, 12 at each of the PGY-1,2, and 3 levels. So, extra training at the PGY-2 level will extend your training, no matter what.

Good luck.

 

[Winged Scapula]

It turns out that there is not an ABIM rule that requires the last two years to be completed at the same program. This is a rule for ABFP board certification.

Thanks for clarifying that...I knew we had discussed it before and had mistakenly remembered it as ABIM. That's what I get for relying on the ol' noggin rather than looking things up.😛

 

[Tipu]

Thanks again for all the advice. We are trying or very best to contact programs to check if they have any sort of PGY-2 openings at all at this point. Can anyone point to a good reliable resource that lists such openings? We are checking www.residentswap.org right now for our leads.

One issue we want to verify is that should we or can we challenge the basis of the termination through a grievance process. Not passing the Step 3 became a non-issue as my wife was granted the extension based on the fact that she eventually had passed it. So, the stipulation of the extension was that her performance will be evaluated and a decision will be made to promote to PGY-3 based on these evaluations. We checked the evaluations that she received from the attendings during this period and they were all "expected performance" or better except for one "Marginal" performance. can a person can be terminated based on one evaluation?

Another issue that was mentioned was that while she was on call in the ICU, a patient was transferred from surgery and she failed to write the correct orders and the patient coded. However, she had verified the orders with the surgeon and wrote what he had recommended. After this incident, she checked with the attending doctor who was in-charge of the patient, and he said this case was mis-handled from the very beginning and she was the last person to handle the patient. She should not bear the brunt of the responsiblity in this case.

So, is it wise to challenge it?

 

[southerndoc]

Another issue that was mentioned was that while she was on call in the ICU, a patient was transferred from surgery and she failed to write the correct orders and the patient coded. However, she had verified the orders with the surgeon and wrote what he had recommended. After this incident, she checked with the attending doctor who was in-charge of the patient, and he said this case was mis-handled from the very beginning and she was the last person to handle the patient. She should not bear the brunt of the responsiblity in this case.

So, is it wise to challenge it?

It is hard to give you advice without knowing all the details. I believe there is more to the story than what you initially described. Just as you added "another issue" in your last post, I am sure there are other issues that have not been mentioned.

Without knowing all details of her evaluations, complaints, concerns, etc., it is difficult and unwise for anyone to give you advice.

 

[radslooking]

yeah, it sounds like a complicated issue. However, she was the last one writing orders, so the orders are in her name. If you want to fight it, I would certainly emphasize the fact that she recieved the orders from a superior, (and that she transcribed them correctly) although Im sure whoever was in charge won't own up to that.

In regards to the marginal evaluation- since she already didn't pass step 3 in the time frame originally promised, im sure they could use any blemish to fire her. they already gave her a break by giving her an extension....i don't think they need much to fire her after that.

In my own humble opinion (not a program director or whatever) I would push slightly on some of the issues you mentioned-and see if they'll let her back in. I wouldnt go to war however. You'll likely lose both the case, and future recommendations.

Thanks again for all the advice. We are trying or very best to contact programs to check if they have any sort of PGY-2 openings at all at this point. Can anyone point to a good reliable resource that lists such openings? We are checking www.residentswap.org right now for our leads.

One issue we want to verify is that should we or can we challenge the basis of the termination through a grievance process. Not passing the Step 3 became a non-issue as my wife was granted the extension based on the fact that she eventually had passed it. So, the stipulation of the extension was that her performance will be evaluated and a decision will be made to promote to PGY-3 based on these evaluations. We checked the evaluations that she received from the attendings during this period and they were all "expected performance" or better except for one "Marginal" performance. can a person can be terminated based on one evaluation?

Another issue that was mentioned was that while she was on call in the ICU, a patient was transferred from surgery and she failed to write the correct orders and the patient coded. However, she had verified the orders with the surgeon and wrote what he had recommended. After this incident, she checked with the attending doctor who was in-charge of the patient, and he said this case was mis-handled from the very beginning and she was the last person to handle the patient. She should not bear the brunt of the responsiblity in this case.

So, is it wise to challenge it?

 

[Doctor Grim]

Do NOT post the program name here, or any details.
That would just be asking for trouble for your wife.
I'd just be movin' on down the road if this were me. You know, I've never had problems with standardized tests, but I think it's kind of weird that programs make people pass Step 3 to go to 3rd year. I don't think my program even had a rule about when you had to take it. I know I didn't take mine by 1/1 of my 2nd year...I took it whenever the heck I wanted to, which I think was the tail end of 2nd year. Only people who were dying to moonlight bothered to take it early. I know a lot of surgery programs make people take it in order to advance to 3rd year, and some will fire you if you don't pass.

If I were this person, I'd get the most positive letters of rec. that she can, then extract a promise from the PD to write as nondamaging letter of evaluation as he is willing to do. Then I'd make sure I see the letter. Then I'd get the attendings that liked me to call some people they know at other programs, and see if there is any way at all to get in to another medicine program. And during the interviews, I'd just spin this as "I know I made a mistake and maybe I'm not a great test taker, but...". Nobody cares that you were done wrong, or think you were done wrong. I think there are many places that would forgive an isolated low test score, but if they think she is malignant and/or lazy, nobody will hire your wife.

Our program (School of Medicine policy) states that all trainees have to SIT for Step 3 before the end of their first year and have to pass by the 18th month into their training or they will not be promoted to PGY3. This happens in reality.

 

[Winged Scapula]

My program had the same rule. You had to sit for it and pass by the start of 3rd year. A few of us waited until the last minute and were still paid as 2nd years although were on 3rd year rotations, until we got our scores back. I'm sure if they had wanted to be a stickler they could have refused to let us advance on more than just paper.

 

[Blade28]

I think our program also has a requirement for you to pass Step 3 before the end of your PGY-3 year.

 

[dragonfly99]

Hmmm...
why to put off Step 1 until 2nd year?
How about 11 months of Q3 and Q4 call with 30 hours in a row call days as an intern, vs. only having 7 months of call as a 2nd year, and thus actually having time to sleep the week before the exam, and maybe even study a little?

 

[Winged Scapula]

Hmmm...
why to put off Step 1 until 2nd year?
How about 11 months of Q3 and Q4 call with 30 hours in a row call days as an intern, vs. only having 7 months of call as a 2nd year, and thus actually having time to sleep the week before the exam, and maybe even study a little?

Or for those of us in the old days, 12 months of q3 call with 36-42 hours in a row call days as an intern versus 12 months of call as a 2nd year...

Seriously no time was better than any other.

 

[dragonfly99]

I'm not trying to get into a p--ing contest with anyone about how hard (vs. easy) my residency was, or say that it was harder than a surgical residency, or harder than doing residency in the "old days". I was giving a reason why someone might very reasonably choose to take step 2 during 2nd year instead of 1st year. My point was that it varies by program. I actually only think I know 1 person from my medicine program who took the test during intern year...there just wasn't a reason to do that and nobody pushed us to do so, and there isn't time to moonlight as an intern, so there was no reason to do so/

But this thread isn't about the USMLE so we probably shouldn't hijack it to discuss the "proper time" to take Step III, I suppose.

 

[Winged Scapula]

I'm not trying to get into a p--ing contest with anyone about how hard (vs. easy) my residency was, or say that it was harder than a surgical residency, or harder than doing residency in the "old days". I was giving a reason why someone might very reasonably choose to take step 2 during 2nd year instead of 1st year. My point was that it varies by program. I actually only think I know 1 person from my medicine program who took the test during intern year...there just wasn't a reason to do that and nobody pushed us to do so, and there isn't time to moonlight as an intern, so there was no reason to do so/

But this thread isn't about the USMLE so we probably shouldn't hijack it to discuss the "proper time" to take Step III, I suppose.

Uhmmm...I was joking. I don't really give a damn how many hours you or anyone else worked during residency nor was I trying to make it a pissing match - read my last line. There was NO good time.

 

[DarthNeurology]

Or for those of us in the old days, 12 months of q3 call with 36-42 hours in a row call days as an intern versus 12 months of call as a 2nd year...

Seriously no time was better than any other.

Do they still do 36 hours in surgery residencies? I have done 36 hour call and found it moderately harder than 24-30 hour call . . . 30 hour call is nice as you just go home and can do stuff for a sort of half a day off.

 

[elwademd]

Hmmm...
why to put off Step 1 until 2nd year?
How about 11 months of Q3 and Q4 call with 30 hours in a row call days as an intern, vs. only having 7 months of call as a 2nd year, and thus actually having time to sleep the week before the exam, and maybe even study a little?

i think you trade off being closer to a lot of the material outside of your specialty during your intern year, for perhaps more time during your 2nd year... but then you have more responsibilities as a 2nd year resident...

as winged said, there isn't really a good time at all.

 

[Winged Scapula]

Do they still do 36 hours in surgery residencies? I have done 36 hour call and found it moderately harder than 24-30 hour call . . . 30 hour call is nice as you just go home and can do stuff for a sort of half a day off.

Depends on the program. I did my first 3 years under the "old rules" so it was par for the course and not infrequently stayed that long post rules. I'd imagine that *most* programs at least try and stay within the rules now.

 

[olivine28]

I didn't take Step 3 until March of my PGY-3 year. My program was not strict about it at all.

 

[DrJosephKim]

Instead of delaying training through appeals and grievances, it may be best to move on to a different position. Would you want to be around if everyone around you knew what had happened to you? How would that impact your interactions with your colleagues, attendings, and students? Sometimes it's better to make a clean start somewhere new.

 

[CambieMD]

The timing of when step III is taken is not the main issue here but it is important. I just assumed that everyone took step III towards the end of internship. It is important to know the policy of your program and to give yourself a little "wiggle" room.

Cambie

 

[Faebinder]

It's threads like these that makes me happy that i finished step 3 last year during my fellowship.