probation

[applecore]

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I am likely to be put on academic probation for poor performance.

If your residency program puts you on probation for academic reasons, how does this affect your chances of transferring to another residency program? Is my current program obligated to tell that program that I am on probation?

Is it better to just quit before I go on probation and look for another position? I am considering this as well. My biggest worry though, is that even if I quit before I go on probation, any program I apply to will wonder why I quit.

Any suggestions would be much appreciated!

 

[Winged Scapula]

Your current program is obligated to be honest to any program considering offering you a position.

However, how much they honor that obligation is dependent on how much they want to get rid of you. It would not be unheard of for a program to leave certain important things out when writing an LOR to your potential new program in an effort to get rid of you...all salespeople do it.

Whether or not you should leave your current program is up to you, but I would venture that staying is probably easier than leaving with a black mark on your record when you might not find another program willing to take you. Unless you are in a specialty which is an extremely easy match and you have some other fantastic qualities, leaving doesn't sound like a good idea to me...you have no way of guaranteeing that even if you left before you were put on probation that you current PD won't mention such things in his LORs.

Besides, what makes you think you wouldn't have the academic problems elsewhere? Its one thing to leave because of an unpleasant and malignant environment or because your spouse transferred jobs, but I suspect that in this situation the devil you know may be better.

 

[Top Gun]

I am likely to be put on academic probation for poor performance.

If your residency program puts you on probation for academic reasons, how does this affect your chances of transferring to another residency program? Is my current program obligated to tell that program that I am on probation?

Is it better to just quit before I go on probation and look for another position? I am considering this as well. My biggest worry though, is that even if I quit before I go on probation, any program I apply to will wonder why I quit.

Any suggestions would be much appreciated!

Or, instead of quitting, you could just use the opportunity to improve your performance, even if you have to go on academic probation. Find out what your weak areas are and work on them. If you have to read more, do it. If your efficiency and time management need improvement, address those areas. Some residents have started out weak and ended up doing much better by their final year.

 

[f_w]

There should be a sticky/FAQ on the whole probation thing.

 

[colbgw02]

Getting into a different program will likely be made much more difficult without a letter from your program director. I would imagine that if you abruptly left just before being placed on probation that you would be less likely to get that letter.

Also, going on probation is not something that can be swept under the rug very easily. Most state licensure boards require you to disclose if you have ever been on probation for any reason. I highly doubt that your current program would neglect to mention this to a new program, nor should you keep quiet about it. Remember, like in politics, sometimes it's not what you did; it's what you tried to cover-up.

 

[f_w]

Some medical boards/hospitals also ask: have you ever resigned from a position while being under investigation or under the threat of being put on probation.

So in a way the threat programs like to use: 'Resign or we will put you on probation and you will never get a job' is an empty one in the sense that any kind of resignation during residency will raise questions later on.

 

[PediBoneDoc]

applecore,

i think you need to be more specific on what type of probation.

we have what we call "double secret probation". this is when we have a plan of remediation and ways of improving a resident's performance without involving the GME. if improvement is made as dictated by an agreement, nothing is documented in the file.

if the probation goes through the university (GME), then there are rules. certain things have to be documented and it DOES go in a permanent file.

in my experience, academic probation has done wonders for our residents. it helps give them guidance. it forces them to take things seriously. most make remarkable recoveries.

if you switch programs to avoid probation, it does not address the reasons you are being placed on probation. those issues will not change in a different program and you may end up in the same position.

 

[Ypo.]

we have what we call "double secret probation".

Wow. That sounds like FBI school.

 

[Winged Scapula]

Wow. That sounds like FBI school.

...or "Animal House".

 

[Blade28]

...or "Animal House".

Oh snap! The attending knows what Animal House is!

🙂 👍

 

[Amelia]

applecore,

i think you need to be more specific on what type of probation.

we have what we call "double secret probation". this is when we have a plan of remediation and ways of improving a resident's performance without involving the GME. if improvement is made as dictated by an agreement, nothing is documented in the file.

if the probation goes through the university (GME), then there are rules. certain things have to be documented and it DOES go in a permanent file.

in my experience, academic probation has done wonders for our residents. it helps give them guidance. it forces them to take things seriously. most make remarkable recoveries.

if you switch programs to avoid probation, it does not address the reasons you are being placed on probation. those issues will not change in a different program and you may end up in the same position.

What sort of things do residents get put on probation for? Not working up patients fast enough? Writing bad notes? Most residents I have seen are pretty autonomous so if they make a very good effort on all their patients how do they get put on probation? Is there a lot of politics involved in this i.e. malignant programs where they grind you down and eventually you mess up?

I thought "double secret probation" is where you are in trouble but they don't tell you so you don't really get a second chance to improve? How many residents are putting on probation? It seems like you used "residents"!

 

[Tired]

I'm confused about how you get on academic probation, other than because of inservice exam scores.

 

[Mad Dog]

You get on probation because people don’t like you.

Basically they make up a lot of crap justification for why you’re a “bad resident”-- ie. nurse smith said you left that patient’s bedrail down!! And that proves you’re a BAD resident!!

It’s a means of exerting control over you, abused to various degrees depending on the program.

This post, sadly, is not being facetious.

 

[f_w]

You get on probation because people don't like you.

Or because
- you suck,
- continue to suck despite strong hints to get your act together,
- turn oppositional defiant when to told that you suck

It's a means of exerting control over you, abused to various degrees depending on the program.

This post, sadly, is not being facetious.

Well, I guess you have been at the receiving end of probation before.

Sure, it can be abused, and particularly in small community programs it tends to be abused.

I trained at a series of larger academic centers and had the 'opportunity' to sit as an ad-hoc resident member on the institutional GME committee at one of them. The few cases of probation that got elevated to the GME committee level where not for 'leaving the bedrail down' but rather for consistent failure to either adhere to a modicum of professional behaviour or just failure to perform the job at the expected level.

Believe me, your protections as a resident are far better than what lets say a junior associate in a lawfirm (=none) or any other non-unionized worker has. You suck, you get fired. No 3-stage hearing process involved.

 

[PediBoneDoc]

f_w thank you for stating what needed to be said. to be placed on probation there is usually a patten of documented problems. we take putting people on probation very seriously. the "double secret probation" that folks poked fun at is the term we use for residents that have had a small series of issues (patient and/or complaints, bad in-training score (like <20th percentile), a series of bad rotation evaluations, etc) that we feel are self limited and they need an slight correction. it is secret. GME is unaware, nothing is on file.

probation can be implemented for a number of reasons. it is usually not for one or two complaints but a pattern that is seen as a problem (tests, bad patient or staff complaints, etc). there is usually a good reason. while on probation, there is a series of test that may be done. you may be evaluated for a learning/processing problem, depression, and/or home problems that may be effecting your work. there will be a plan for remediation, a ways of evaluated progress, and clear objectives.

i am on the GMEC and f_w is correct in that when the probation reaches the GME level, there are multiple documented problems with no evidence of an improvement on the stated objectives. to get to the GME stage, you have cause a significant problem with no or little evidence of improvement.

as far as residents on probation, i have been at 3 different institutions with residents. i have seen multiple residents on probation. only one who was fired.

 

[Mad Dog]

Well, I guess you have been at the receiving end of probation before.

No, in fact I haven’t.

However, at the large academic center where I trained there was pretty much a resident or two from each year on probation or “imminent” probation, and I knew those residents, and I, and everyone else, knew it was 100% B.S.

If by “modicum of..behaviour” however, you mean sucking up appropriately to the key attendings and chiefs.. and by “performing..at the expected level” you mean making sure you look good despite whatever faults or inconsistencies occur, then I completely agree with you!!

The worst shame is when someone has been so successful with their “behavior” and “performance” that they take it as their due to further feed this system, and even feel “justified” in doing so. I stand for the unpopular med student or the unpopular resident because I’m not a stooge. You, my friend, are what I stand against.

f_w thank you ... f_w is correct ...

I don't think I could have asked for a better supporting reply!

there is usually a good reason..

It must be nice to believe all that.

 

[f_w]

I stand for the unpopular med student or the unpopular resident because I’m not a stooge. You, my friend, are what I stand against.

ROFLMAO, this is probably the first time in my life that I am cited as an example of 'the system' by anyone.

More than once, I was actually the 'unpopular resident', usually if I couldn't shut up jabbering about an institutional problem the higher ups preferred not to hear about. It did buy me a visit to the chairmans office once or twice, but they where smart enough not to threaten probation (the only time they pulled out the 'p' word was after I scored the 5th percentile on the inservice exam until they realized that I had been on-call the night before and fallen asleep during the test )

 

[Amelia]

probation can be implemented for a number of reasons. it is usually not for one or two complaints but a pattern that is seen as a problem (tests, bad patient or staff complaints, etc). there is usually a good reason. while on probation, there is a series of test that may be done. you may be evaluated for a learning/processing problem, depression, and/or home problems that may be effecting your work. there will be a plan for remediation, a ways of evaluated progress, and clear objectives.

i am on the GMEC and f_w is correct in that when the probation reaches the GME level, there are multiple documented problems with no evidence of an improvement on the stated objectives. to get to the GME stage, you have cause a significant problem with no or little evidence of improvement.

as far as residents on probation, i have been at 3 different institutions with residents. i have seen multiple residents on probation. only one who was fired.

I am not a resident either, but obviously there is a degree of subjective evaluation, and we have all seen residents/students who are told on almost a daily basis that "they suck", and some of us would probably agree that in a different residency program they would do better and not be on probation (right?), i.e. if there is an attending who just goes around "whacking" residents then if this person wasn't around everyone would be happier, work would be better, and fewer people on probation? It is hard to believe that someone who made it through medical school into residency suddenly becomes "incompetent" and then has a "miraculous recovery" right? I.e. there must be a huge power component many people in academic medicine who have power expect their residents to be subservient in a sort of weird way I think

 

[PediBoneDoc]

i think that med student and residents believe that putting someone on probation some how give the attendings a sense of power. not so much. reasons i have seen residents placed on probation. multiple complaints of sexual harassment, concerns about alcohol or drug abuse, anger management issues. when we use probation, there has been pattern of problems with counseling and not changes. i have not seen incompetence as a reason for probation. i have encountered a number of residents that have had problems and the program of remediation has made huge changes in there overall performance.

i can only speak for what we do. probation is not used to get rid of residence. it is not like a scarlet letter where everyone in the program knows. it is between our chairman, the resident, the gme and the resident's mentoring physician. it is secret. it is not about power. i have personally never put someone on probation.

when i was a chief resident, i was involved in a several resident's probations. i saw both ends and fought for my fellow residents. in our program, every resident who has been on probation has made tremendous strides forward. it is not Us versus them. in our program, it is not a popularity contest.

 

[Mad Dog]

ROFLMAO, this is probably the first time in my life that I am cited as an example of 'the system' by anyone.

More than once, I was actually the 'unpopular resident', usually if I couldn't shut up jabbering about an institutional problem the higher ups preferred not to hear about. It did buy me a visit to the chairmans office once or twice, but they where smart enough not to threaten probation (the only time they pulled out the 'p' word was after I scored the 5th percentile on the inservice exam until they realized that I had been on-call the night before and fallen asleep during the test )

Ok, fair ‘nuff 😉

My chair used to just shake his head when he saw me, half the time they were complaining about me, and the other half I was coming in to complain about them! It is though what it is, I guess we all learn after a while to just let it ride. There were some attendings though that just hated me, glad that’s over!

 

[3dtp]

f_w thank you for stating what needed to be said. to be placed on probation there is usually a patten of documented problems. we take putting people on probation very seriously. the "double secret probation" that folks poked fun at is the term we use for residents that have had a small series of issues (patient and/or complaints, bad in-training score (like <20th percentile), a series of bad rotation evaluations, etc) that we feel are self limited and they need an slight correction. it is secret. GME is unaware, nothing is on file.

probation can be implemented for a number of reasons. it is usually not for one or two complaints but a pattern that is seen as a problem (tests, bad patient or staff complaints, etc). there is usually a good reason. while on probation, there is a series of test that may be done. you may be evaluated for a learning/processing problem, depression, and/or home problems that may be effecting your work. there will be a plan for remediation, a ways of evaluated progress, and clear objectives.

i am on the GMEC and f_w is correct in that when the probation reaches the GME level, there are multiple documented problems with no evidence of an improvement on the stated objectives. to get to the GME stage, you have cause a significant problem with no or little evidence of improvement.

as far as residents on probation, i have been at 3 different institutions with residents. i have seen multiple residents on probation. only one who was fired.

pedi and f_w,
Whiile I respect your experiences, I have seen a very different, and ugly side of this equation. Five residents fired in one year by one program director. Three more threatned with probation. Even if all of these were completely warranted, does this record not say something about the program director's judgement? Either the PD was a very, very poor judge of character in selecting residents, or in the alternative, a very, very poor educator of residents, or perhaps a combinationof the two. In 60% of these, the terminated residents have gone on to successfully complete other residencies without incident, not because they were remediated. In two of these cases, there was no (zero) record of any remediation other than vicious, unkind and untrue rumors that were spread throughout the program, by persons unknown.

Like you, I have been at four institutions, either as a resident or as faculty. I have seen excellence as you have described, but I have also seen the converse. While the ACGME requires a reasonable and reasoned review/appeal process, and at my current institution, this appeal process is forged in titanium, at the institution above described the resident appeals process was changed on whims, whenever it appeared that the resident appealing might be successful. This is a 25% problem rate (n=4).

As pointed out, a resident accused/probationed/terminated, justified or not, faces an exceedingly difficult task of redeeming himself.

I agree that, from time to time, there are residents who do not cut the mustard, but I suspect these are relatively rare. Five at one modest sized program in one year seems a tad high.

And super secret, double classified probation doesn't cut it either. If you are in this situation, and you don't report it and the board finds out, you are screwed, as one hapless physician applying for a particular state's license found out, when the "non-probation" probation was uncovered by the board's investigators. In this case the state board reprimanded both the resident and the program director who advised her to not report the event.

 

[Mad Dog]

i think that med student and residents believe that putting someone on probation some how give the attendings a sense of power. not so much. reasons i have seen residents placed on probation. multiple complaints of sexual harassment, concerns about alcohol or drug abuse, anger management issues. when we use probation, there has been pattern of problems with counseling and not changes. i have not seen incompetence as a reason for probation. i have encountered a number of residents that have had problems and the program of remediation has made huge changes in there overall performance.

i can only speak for what we do. probation is not used to get rid of residence. it is not like a scarlet letter where everyone in the program knows. it is between our chairman, the resident, the gme and the resident's mentoring physician. it is secret. it is not about power. i have personally never put someone on probation.

when i was a chief resident, i was involved in a several resident's probations. i saw both ends and fought for my fellow residents. in our program, every resident who has been on probation has made tremendous strides forward. it is not Us versus them. in our program, it is not a popularity contest.

Yes, those things are real issues. You seem to be at a very humane institution. I just saw the abuse, meaning the abuse of the probationary power. There wasn’t a single resident I felt deserved it, and there were some not-so-fine specimens that came through that program. It’s a black mark forever and forever. I don’t see why we have to do that.

 

[PediBoneDoc]

3tdp: i know your situation and agree with what you are saying. do understand the the so mocked "double secret probation" is not a true probation. it is noting some attributes or problems that are questionable and need further evaluation and extra mentoring. these are not to hide egregious mistakes or errors in judgment and thus is not a board issue. trust me, anything we do has to first go through legal before decisions are made. once official probation, certain things have to occur and documents placed in a permanent record. if a program is place multiple people on probation without merit, then it is a program issue. if multiple people are fired as well, it is a program issue. the documentation is the key element.

i think it is unfair to say all residencies and institution are bad and treat residents poorly. on the flip side, there are bad residents and attending physicians. as a whole, physicians (both attendings and residents) are good people trying to do the right thing. as someone who is education residents, it is my, attending, obligation to guide a residents in their education and if i see a problem, correct it. on occasion, probation is warranted and should be used judiciously to improve someones documented problems. for me, it is not personal. for our residents who were on probation, they truly needed some extra assistance. i have spoken with them afterwards, and most have come through the process an improved physician. now, we have not used this process yet to fire a resident. i personally see firing a resident as a failure on our end, unless the resident is a sociopath.

 

[PediBoneDoc]

to the OP:
sorry for getting a little off topic and discussing the validity of probation and so forth. from my prospective, before you choose to make the decision of switching programs, you must first be self critical. if the issues your current program do have merit, they will continue to be problems in your new program. if it is completely a personality conflict and you feel your program is persecuting you for these personality differences, a change of venue may be in order. this is not for me or others on the forums to decide. all of our opinions are skewed by our experience and limited knowledge of your case. i am personally a resident/med student advocate and will tend to side with the resident. there are times when probation is needed and should be used only as a last resort after other steps have been taken to rectify noted problems (we call it double secret probation), not as a way of penalizing an unpopular resident. in my opinion, whether i personally like a resident or not has no bearing on their evaluation. in fact, i am probably fairer in cases when i done particularly gel with a resident because i try to grade totally objectively and state only facts. this doesn't happen often because i am awesome 😀.

here is an article reviewing this topic.

 

[southerndoc]

i think that med student and residents believe that putting someone on probation some how give the attendings a sense of power. not so much. reasons i have seen residents placed on probation. multiple complaints of sexual harassment, concerns about alcohol or drug abuse, anger management issues. when we use probation, there has been pattern of problems with counseling and not changes. i have not seen incompetence as a reason for probation. i have encountered a number of residents that have had problems and the program of remediation has made huge changes in there overall performance.

i can only speak for what we do. probation is not used to get rid of residence. it is not like a scarlet letter where everyone in the program knows. it is between our chairman, the resident, the gme and the resident's mentoring physician. it is secret. it is not about power. i have personally never put someone on probation.

when i was a chief resident, i was involved in a several resident's probations. i saw both ends and fought for my fellow residents. in our program, every resident who has been on probation has made tremendous strides forward. it is not Us versus them. in our program, it is not a popularity contest.

It may be contained within the program while the resident is there, but I would assume you must report any probation, ethical, or other issues to hospitals when a graduating resident applies for credentialing. At least my state license and hospital credentialing applications asked specifically if I had ever been on probation, in remedial training, disciplined in any way, etc. (Thankfully I haven't.) I assume that they will also ask my program director this, and I would expect her to answer honestly.

Regarding attendings having a sense of power by putting a resident on probation, I would think it would be a major headache with a lot of paperwork for an attending to suggest that someone be placed on probation. It's probably too much work for someone to do it solely based on a sense of power.

 

[Tired]

It's almost like folks are talking about two different issues: probation for sexual harassment, behavior issues, drug use vs "academic probation" which I am unfamiliar with in the residency setting, but assumed had something to do with knowledge base, inservice exams, etc. If the OP was put on "academic probation" what kinds of things would he/she have to have done to warrant that?

 

[PediBoneDoc]

It's almost like folks are talking about two different issues: probation for sexual harassment, behavior issues, drug use vs "academic probation" which I am unfamiliar with in the residency setting, but assumed had something to do with knowledge base, inservice exams, etc. If the OP was put on "academic probation" what kinds of things would he/she have to have done to warrant that?

tired ... hope the residency is going well. many programs will use a poor in-training score as a reason to placing someone on "academic probation." for our program, more commonly it is because of a pattern of problems. poor performance on multiple rotations, poor in-training scores, and a "perception" of lagging behind their peers (residents at the same level). one bad evaluation doesn't get you one probation. 3 straight rotations of poor performance without change will.

our program runs things through a "chain of command". an issue is noted. the chief of that service (resident senior) is informed of an issue and asked to speak with the resident and make changes. if nothing improves, it goes to the executive chief resident and/or chief of that division (peds, joints, spine, etc). if no change is noted, then to the chairman/residency director. if this is seen as a single event (i.e. perfect storm), the resident is counseled. if it is a trend and the resident has been counseled about these issues before, then a more formal mentoring and plan for improvement will be set up (i.e. double secret probation). we keep a close eye on the resident with weekly meetings with their mentor. simple goals are set and if met, no action is taken. if the resident has no made progress, then we can place them on academic probation. once on academic probation, we can have the resident evaluated for learning disabilities, psychiatric disorders (like depression), and other social and personal issues. this information in private and we are not privy to that information. if something is noted, suggestions of treatments are made.

the most common thing that has been found is information processing problems. the resident can read and regurgitate the information for a test but has difficulty in translating that information into patient care. occasionally, someone will be found to be depressed. i don't think we have picked up on any sociopaths or borderlines, but i wonder sometimes. (these are things i know about because the residents have actually told me)

It may be contained within the program while the resident is there, but I would assume you must report any probation, ethical, or other issues to hospitals when a graduating resident applies for credentialing. At least my state license and hospital credentialing applications asked specifically if I had ever been on probation, in remedial training, disciplined in any way, etc. (Thankfully I haven't.) I assume that they will also ask my program director this, and I would expect her to answer honestly.

Regarding attendings having a sense of power by putting a resident on probation, I would think it would be a major headache with a lot of paperwork for an attending to suggest that someone be placed on probation. It's probably too much work for someone to do it solely based on a sense of power.

as far as probation goes and reporting to the board, if it is a formal probation then it must be reported. the board is more worried about problems in behavior (meaning abusive behavior and psychological problems) than your in-training score. they are about protecting the public from bad physicians. if you did poorly on you in-training but pass your specialty boards, they don't really care.

most people don't need full probation, they just need a little help and guidance to improve. probation is a huge headache for everyone involved and a lot of paperwork. we would rather not have someone on probation. but for a consistent pattern of problems without any noted change after multiple attempts at correction to no avail. then probation it is.

 

[f_w]

But it has to be said that many smaller programs don't have an elaborate 3-stage remedial process with resident peers involved. Often, probation can be issued by a cangaroo court made up of the program director, the chairman and some ad-hoc faculty member (usually one that hates residents anyways). At times, it is indeed a tool to remove residents that someohow rubbed a faculty member the wrong way. Those places also tend to be the ones where the PD wields this as an overt threat whenever the underlings squeal about something like work hour overages or the demand to perform phone operator work for a faculty members private practice.

ACGME just requires 'A' process, it doesn't require a fair process. If you run a residency program, you control the paperwork. If your written policy is: 'PD may fire resident at will. a sham hearing will be performed before the firing.' ACGME will be fine with it.

 

[dynx]

a cangaroo

Part aluminum beverage container...part marsupial...ALL BADASS.

 

[Blade28]

Part aluminum beverage container...part marsupial...ALL BADASS.

👍

 

[benjee]

By any chance, dose anyone know how the credentialing office find out if one has any history of probation or termination??

 

[f_w]

Throughout your professional career, anytime you apply for hospital staff priviledges or a medical license, a form-letter/questionaire goes to your program director (or his/her designee) asking for information about your conduct and qualifications during residency.

You can get a felony pardoned and a misdemeanor expunged, you will never get rid of that 'yes' on the credentialing application.

And don't even think about lying. Getting your license/credentials denied because you where a temporary slacker in residency is unlikely. Getting it denied for lying on a license application and being found out about is permanent.

 

[PediBoneDoc]

as a member of the GME and an internal reviewer, the ACGME requires more than just a process. the steps must be spelled out pretty clearly. as far as program directors and placing probation, there are good directors and bad ones. at our institution during an internal review of it is noted that there are multiple residents on probation and/or who have been fired, it is a red flag and is investigated. if there is a hearing, it is at the GME level not the program level. so the people reviewing things are usually unfamiliar with the person directly.

also the ACGME is being run by mostly educators, not physicians. except for ortho and i think ER or radiology, the site reviewers are all educators and not physicians. they just gather the facts.

probation is serious and therefore we reserve it for those who need more than just a good pep talk. and f_w is right, never lie to the board. that is considered fraud and reportable to the NPDB.

 

[Mad Dog]

It's almost like folks are talking about two different issues: probation for sexual harassment, behavior issues, drug use vs "academic probation" which I am unfamiliar with in the residency setting, but assumed had something to do with knowledge base, inservice exams, etc. If the OP was put on "academic probation" what kinds of things would he/she have to have done to warrant that?

All “academic probation” means is that it was based on poor performance on your clinical rotations.

And like everyone knows, your rotation evaluations are based purely on objective factors, right? Because no attending would ever let their personal feelings sway their assessment of your knowledge and skills!!

And since a rotation evaluation is made up many individual evaluations, clearly there is no way any particular attending’s poor evalution could hold sway over numerous other positive evaluations, to make the total assessment of an otherwise fine rotation into a “poor performance”!!

It’s a kangaroo court even before it becomes a kangaroo court. A malignant attending will cover their bile by focusing on your clinical ability. And if you score 99th percentile on your in-service, then they’ll just say you have “book smarts that you can’t translate into patient care.” (Thank you PediBoneDoc!) If they get you, it will under a clinical facade.

And in determining your overall performance, the program director weighs your individual evals however he pleases. One single key attending can trash you “academically,” then overshadow handfuls of other positive evaluations such that you get an overall assessment of “poor performance.” You get that same attending on a subsequent rotation, or one of his hangers-on, and now you have a “pattern” of poor performance. And soon you will be looking the “p” word in the eye.

So that kids is how “academic probation” works!

Compare that of course to the politically savvy but otherwise dim resident who gets spoon fed on rounds and barely scrapes by on each in-service, but sucks up well and by evaluation is a bonafide clinical superstar!

 

[PediBoneDoc]

although i agree that evaluations are for the most part subjective, there should be a process. one bad evaluation is seen as a blip. we are clearly aware of resident/attending differences. those differences are brought up to the program director (usually by the chief resident) and unless there are other bad evaluations, we disregards them. a one time bad evaluation is no reason for probation. we may watch you closer but no probation. we have a husband and wife attending duo. there have been several residents she had disliked for one reason or another. i have NEVER known her husband or have her opinion change his view.

for our program, probation is reserved a persistent pattern of problems and not one evaluation. i will state again, it is not a power issue. all though a majority of the academic probations are done for poor in-training scores. a resident with persistently poor evaluation over several rotations, who has not improved performance after being counseled. although the perception is attendings vs residents, it is not; malignant attendings don't get censured or disciplined, they do.

as mad dog says, book smarts DO NOT always correlate with clinical or surgical skill. and a single bad attending evaluation without others agreeing does/should be weighted to heavily.

mad dog u can spin what i say which ever you want. i am sure we can all remember 1, 2 or 3 situations where we feel someone was treated unfairly. truthfully from a program stand point, it is a black eye. it is not a power trip. it says the program is either not teaching well or bad at choosing residents.

the push by the ACGME is to uses 360 evaluation system. besides the attending, it takes in input from multiple healthcare workers, from nurses, to PA's, and other ancillary service workers. this is instrument is being used to help to prevent what mad dog pointed out.

 

[Tired]

the push by the ACGME is to uses 360 evaluation system. besides the attending, it takes in input from multiple healthcare workers, from nurses, to PA's, and other ancillary service workers. this is instrument is being used to help to prevent what mad dog pointed out.

That makes me want to get out of residency all together (and it may, depending on which nurses they survey for my eval).

No one ever asks me for my input before their performance evals.

 

[f_w]

the push by the ACGME is to uses 360 evaluation system. besides the attending, it takes in input from multiple healthcare workers, from nurses, to PA's, and other ancillary service workers. this is instrument is being used to help to prevent what mad dog pointed out.

Those are the really scary ones.

The people being surveyed often:
- have no idea how to evaluate what the resident actually does
- are not part of an academic system where evaluations go both ways (attending evaluating residents and vice versa)
- don't have the educational knowledge and skill required to provide an evaluation
- have no idea how stuff they make up in that 360 eval can screw with someones career.

In my experience, they often boil down to a 'like that resident' vs. 'don't like that resident' thing.

The main problem I see with them is that the resident can't tell any nursing or ancillary staff anymore if they f### up. E.g. if someone with their lazyness puts your patients at risk, you can't afford to point it out to them or go to their supervisor anymore because there is a risk of that miserable b#$*^@ getting selected for your 360. Don't ask me how I know that.

 

[Mad Dog]

one bad evaluation is seen as a blip.

No, its true. A bad eval or two is expected. Even the superstar residents get one now and then, and no one really makes a big deal.

A “pattern” of poor performance however is extremely easy to manufacture. People in medicine tend to force alliances and pick sides. Someones name “gets around,” and that bad eval turns into 3, with those other attendings perhaps no one you’ve ever even met! Bad evals can be amplified into a pattern as easy as pie. Chiefs will pass the names of the residents they don’t like to the chief on the next rotation, and attendings do the same thing. Who are those new attendings likely to side with?

It’s the program director’s call however what constitutes a pattern. And like your evals, this also is completely subjective. In almost any situation its not hard to pull together enough bad or just tepid evaluations to state there is a “pattern.”

I’m not trying to be the resident “conspiracy theorist” here, that every program is out to get you. For the most part, they’re not! I do agree that most program directors want to produce physicians that will be a credit to their program and to the medical profession. However, the points I’m making are that:

1. People get in trouble in residency based on their personality, (lack of) polical savvy, and interpersonal interactions, and rarely if ever due to any legitimate clinical issues.

and 2. The game is rigged. They have the power, they make the rules, and they will gang up and crush if they so desire. And the techinque of choice, which also doubles as a way to get rid of you entirely should they desire, is probation, the rules for which they also manipulate and control.

Otherwise, residency is great, right?

 

[f_w]

I’m not trying to be the resident “conspiracy theorist” here, that every program is out to get you.

It just sounds like it.

1. People get in trouble in residency based on their personality, (lack of) polical savvy, and interpersonal interactions, and rarely if ever due to any legitimate clinical issues.

People may get in trouble for those things. The people around me that got canned along the way plain sucked. It was clear to everyone who had to suffer alongside them, the attendings and everyone else involved.

and 2. The game is rigged.

Yes, there are programs where the disciplinary process is rigged. But there are just as many programs where this is a sincere and fair undertaking.

 

[PediBoneDoc]

f_w and mad dog bring up all good and valid points. we are all human and flawed by our nature. every once and a while someone gets screwed but the system (ACGME and GME) has been set up to help prevent some persecutions for personality conflicts. although probation is decided on by the program director, it can only be given once and has to have an end date. the next step would be for dismissal and the decision for dismissal goes through the GME. The GME is usually representatives from all different departments and/or divisions with resident members. the program directors have little effect on that committee. it is just about the facts. to be fired (for cause), you have to have pretty clear cause.

although this goes a little off the OP's question, i want to bring somethings to light that you all may or may not be aware of. you all complained about the 360 evaluations. i want you to know that 360 evaluations are becoming a requirement for hospitals across the board. hospitals are being require by JCAHO to have these instraments in place. CMS (medicaid/medicare) may start to use these when evaluating physicians for the P4P (pay for performance). this has just recently been added to the resident evaluations. you don't want your evaluations done by the nurses and clerks while in residency. how would you feel if you were in private practice and you medicare payments where altered because of these evaluations? oh, and you can say that you won't take medicare. well, mos insurances follow medicare, and unlike many years ago, medicare is a good payor. insurance fees schedules are based on medicare rate (i.e. 90% of medicare, 105% medicare, 80% medicare). well come to the new generation of medicine.

 

[Mad Dog]

The people around me that got canned along the way plain sucked.

The people I thought sucked were the ones who stabbed their co-residents in the back, or stole all the credit while re-attributing the blame. In otherwords, the “successful” residents.

On the ones embroiled in disciplinary problems, I just felt bad for them. As mentioned above, I have certainly encountered some not-so-fine specimens of humanity in medicine. But I don’t think anyone deserves what I saw meted out to those given probation.

My personal impression is that the ones in the first category, who are good at working the system, grow up to be the most insufferable attendings. And the ones in the second category certainly don’t get any better from all the censure and abuse. They just learn to repress enough to get through. Personalities are hard to change.

It would be interesting to do a “then and now” comparison. Once out of the narrow scrutiny of residency I would bet there’s no increase in professional problems between either category.

 

[Mad Dog]

CMS (medicaid/medicare) may start to use these when evaluating physicians for the P4P (pay for performance).

ARGGHHHHHH!!! please don’t get me started on P4P!!

well come to the new generation of medicine.

A brave new world indeed!!

 

[Annette]

PediBone, I'm confused. Probation is reviewed by GME? A hospital committee? Or is AGME? Or is it only for firing for cause?

 

[PediBoneDoc]

PediBone, I'm confused. Probation is reviewed by GME? A hospital committee? Or is AGME? Or is it only for firing for cause?

good question annette. probation is a departmental decision (i.e. program director). there are criteria for placing people on probation. those policies and procedures are usually provided by the GME. at our university, there is a GME Ombudsman available to assist any trainee through this process. probation has a limited time, so either they come off probation and go about there merry way, or their contract is "not renewed". at the "firing" period, this is when the GME gets formally involved along with the Dean of the university. this is in the university case. i am not sure how it works when a program has no college or university affiliation.

the gme reviews programs. when doing internal reviews, the number of people on probation and the results of the probation are reviewed. a red flag goes up when there are multiple residents on probation or being fired. the ACGME also reviews this same information. it is included in the program information form (PIF) and on reviewing this the program could get cited for this problem if it was viewed as unfair.

as far as the hospital is concerned, i don't thing they will be involved unless the are the residency sponsor (instead of a university) or the situation directly involves them.

(oh and i love my new spelling of welcome .... whispering to self "IDIOT")

 

[f_w]

i am not sure how it works when a program has no college or university affiliation.

Those are the scary places. They typically have a departmental 'GME committee' consisting of the PD and himself and maybe the department chair. Without much accountability, this 'committee' can pretty much hire and fire residents using the 'due process' of the policies they wrote themselves. In these smaller programs, the resident can face a 'judge-Dredd' situation with the PD being the police, judge and executioner in one instance.

 

[Annette]

So the ACGME doesn't review individual probations or firings? Do they review the cases if there are too many red flags?

Do the residencies have to report probations (not the double secrete kind) to ACGME? If you have been a vicitm of a Judge Dredd situation, is there a way to check with ACGME, or to have them review the situation? I guess I'm asking if the ACGME would act as a completely independent judge of a stituation as protection for the residents against the rare abusive PD?

 

[PediBoneDoc]

So the ACGME doesn't review individual probations or firings? Do they review the cases if there are too many red flags?

Do the residencies have to report probations (not the double secrete kind) to ACGME? If you have been a vicitm of a Judge Dredd situation, is there a way to check with ACGME, or to have them review the situation? I guess I'm asking if the ACGME would act as a completely independent judge of a stituation as protection for the residents against the rare abusive PD?

well as we all know the ACGME definitely can see double secret probation unless they are smart and bring their Captain Crunch decoder ring 😉.

i think there is a misconception of what the ACGME does. it just accredits the programs. if they are not accredited, the program can't receive government funding.

ACGME statement:

The Accreditation Council for Graduate Medical Education is a private, non-profit organization that accredits more than 8,000 residency programs in 120 specialties and subspecialties. Formed in 1981 through a consensus need in the medical community for an independent accrediting organization for residency programs, the ACGME's mission is to improve the quality of health care in the United States by ensuring and improving the quality of graduate medical education programs. The ACGME's member organizations &#8211; the American Board of Medical Specialties, American Hospital Association, American Medical Association, American Association of Medical Colleges and Council of Medical Specialty Societies &#8211; nominate members to the ACGME's Board of Directors. The board also includes two resident representatives, the chair of the Council of Review Committees, three public members and a federal government representative.

Accreditation is voluntary. However, residency programs must be ACGME-accredited to receive Medicare graduate medical education funds, and residents must complete an ACGME-accredited residency program to be eligible to take board certification exams. Twenty-seven residency review committees (one for each of the 26 specialties and one for transitional year programs) are responsible for reviewing programs. Each residency committee comprises 6 to 18 volunteer physicians appointed by the ACGME's member organizations and the appropriate medical specialty boards and organizations. The RRCs meet two to three times a year to review programs. They are assisted in their work by more than 100 ACGME staff members.

Residency programs are visited onsite by an ACGME field staff member, on average, once every two to five years. Before a site visit, the program director fills out a program information form, or PIF, in which the program director provides information and documentation about the program. Residents also complete confidential online surveys a few weeks before the site visit. After the ACGME field representative conducts the one-day site visit, he or she writes a report on the program. The RRC makes its decision on whether to grant accreditation based on its review of the PIF and field staff report. In order to be accredited, programs must substantially comply with the ACGME's common program requirements and the specialty-specific requirements. Programs in good standing receive full accreditation, while those with deficiencies that must be corrected are put on probationary accreditation. If a program fails to correct its deficiencies, accreditation can be withdrawn. In that case, the program must shut down. In most instances, the sponsoring institution may reapply for a new program in that specialty, but this new program must comply with all accreditation standards in that specialty.

my understanding is that the ACGME will get involved if a complaint is filed or if on review, there is a pattern of frequent probations and firing. the GME and university counsel are more commonly involved for the probations that proceed to the next level.

 

[Mad Dog]

So the ACGME doesn't review individual probations or firings? Do they review the cases if there are too many red flags?

Do the residencies have to report probations (not the double secrete kind) to ACGME? If you have been a vicitm of a Judge Dredd situation, is there a way to check with ACGME, or to have them review the situation? I guess I'm asking if the ACGME would act as a completely independent judge of a stituation as protection for the residents against the rare abusive PD?

Keep in mind that like pedidoc is saying, the ACGME regulates programs in a global sense, ie. its power lies in granting or revoking accredidation for the program as a whole. They have no power, nor would they want the power, to meddle in the actual internal actions of a program. If they saw a significant ethical violatation, like a whistle-blowing resident getting fired, they could put the entire program on probation (but never would)-- but they couldn’t force the program to re-hire the resident. They just don’t have that kind of power.

How well a program gets away with thumbing its nose at the ACGME varies. Many programs still consistently ignore the 80 hour work week, but it’s a rare event for the ACGME to step in. A few years ago they came down on Hopkins because a resident there reported his own program. And his reward? He was pretty much forced out, the program suffered some momentary indignity, and then everything went back to the residents carefully under-reporting their hours.

Generally the recourse one has with probation or any other residency “situation” is to make it as painful for them as they are making it for you. If the problem is with a particular attending, that attending’s abuses can be reported, and he can not only be discredited but censured himself. If the case against you is more a “web” of manufactured B.S., a well organized lawsuit will allow their legal department to force the department to put a halt to things very quickly. It costs a lot of time and money to defend these kinds of suits, particularly when the only justification is that the person “sucks.”

Of course, if you really are just a “bad” resident I guess you could try to change. I really don’t know however what a “bad” resident is. The ones I saw who ended up on probation were never better or worse than anyone else, they just didn’t play the game very well.

 

[f_w]

If the case against you is more a "web" of manufactured B.S., a well organized lawsuit will allow their legal department to force the department to put a halt to things very quickly. It costs a lot of time and money to defend these kinds of suits, particularly when the only justification is that the person "sucks."

Courts rarely to never step into 'academic' disputes.

The only time a lawsuit (or just the threat thereof) can be useful is if the program didn't stick to their own rules or did something really egregious (like firing you for being black, lesbian, black&lesbian or because the aryan nation told them to). If they have a stack of evals that say that you didn't fulfill the job requirements and they followed their protocol of hearings and probation, no court is going to order them to rehire you.

Oh, and I would suggest that nobody stakes their hopes on the ACGME to fix things that are wrong with their program. The ACGME functions like JCAHO. They come, pull out the policy folder, read through it, talk to some hand-selected staff members, leave and write their report.

 

[Mad Dog]

Courts rarely to never step into 'academic' disputes.

Not sure what you're saying.

A court steps into any dispute where one party has filed suit against another. Unless it settles before going to court. There is certainly a basis on which a resident can sue their program.

Personally I also feel many cases have suffificient merit to win in court. The objective though, in cases of B.S. probation, is just to get both sides to drop their weapons and let the resident complete the program.