Proposing Standardizing Contract Renewal Process

[RespectResident]

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Dear All,

I am here to propose to hold ACGME accountable for their lack of ability to protect residents when it comes to issues of dismissal/contract renewal. Based on their own policy which each program must abide in order to be accredited there are six core competencies that residents must demonstrate to excel. Each core should be weighted equally as lacking one is unacceptable to be a "good" physician. Thus medical knowledge should not be placed above morale behavior and vice versa. Thus, if one resident demonstrate to pass or above average throughout the year should be allowed to continue onto the next year or given the option of transferring to another residency program if subjective issues are at play.

This electronic evaluation system should be used for something instead of just a mere decoration. Why spends all these tax payers money when we don't even utilize it properly and to its fullest extent. It is a point system thus to calculate an above average performance is easy. This standardization will objectify one's performance throughout the year by attending who have actually worked with the residents instead of just one person's opinions. Let's face it. We cannot all get along with everyone but if this someone is your PD, you are ruined for the rest of your life and destined to work in McDonald for the rest of your lives? PDs are humans. They have flaws like humans. They have emotion like humans. To say that they can evaluate residents without personal preference is like saying he is not humans. Surely in theory PD's are supposed to be unbiased but again that is a fantasy. The benefits of using such standardization have many. First of all, this will be a unbiased objective language for PDs to communicated. Numbers are numbers. There is no emotional connotation to them. Words on the other hand depending on the tones and usage can be taken quite differently. The second benefit is it can be used in a long run with consistency. PDs don't stay on their positions forever but as a PD he/she is responsible for all previously graduated residents LOR's and reference and what not. The new PD might not know the previous resident on a personal level thus his/her reference will be purely based on the opinions of the original PD, who might be biased or unfair at the time. By giving a numeric value, a residents performance can be mentioned across board and throughout the years they trained. Not a tunnel vision of one's opinions. The third benefit of such is to protect residents right as well as the program. This will no longer hold one PD accountable for a resident's dismissal rather an entire department. And let's face it. If a resident has across the board bad evaluation from all of the attending on different services the chances of them being competent in all six cores are slim. It's possible to receive a bad evaluation from a biased attending but it's another story to get bad evaluation from many. The suit filed by Nigro would have been easily prevented if such rule was followed. It would have saved the reputation of the PD and one million dollars from the hospital.

I feel that ACGME has this disbelief that the current system installed in their policy is working perfectly. They are working under the assumption that there is no retaliation and everyone is professional. Unfortunately this is not a perfect world and ACGME needs to wake up. A DIO is not going to jeopardize it's working relationship with a PD for a mere sake of a junior resident. Because the two individuals work for the same entity and most likely have personal relationships (they probably play golf together) DIO's stance is likely not objective at all. By providing such standardized system this will allow a clear-cut look of the residents performance. There will have no question for the most part and it also gives all parties involved something to argue about. It hard to argue with a number based on an entire performance, doesn't it?

I urge you all to write to ACGME and wake them up. There are many residents whose lives are ruined because of the lack of authorities of ACGME over the residency program. It is ACGME's responsibility to train physicians in adequate and non-hostile education environment. They are the ones set up the system so they should be the one enforcing it. They claim they have no authority to influence a PD decision but they certainly have authority to discredit a program immediately. After all if a program in inadequate ACGME is inadvertently allowing a poor residency program to graduate substandard physicians. This will ultimately affect the quality of patient care and it's due negligence. On top of this, those terminated residents clearly suffer from emotional distress, which is again due to ACGME's inability to respond to the needs of residents. They know what is going on yet they choose to ignore it. If the resident has an overall passing scores (or above average scores) yet still face termination it should be ACGME's responsibility to find another position for this resident because obviously the present program is not abiding the accreditation policy set forth by the agency itself therefore not qualified to train residents at all (or at least not this one). ACGME has a conflicting stance on residency program and its ineffective role in establishing what an ultimately pro-patient system is dangerous.


Looking at the posts, many of them suffer from depression. Some try to stay positive but some simply cannot get out of it. Some end up spending more years in training because of some arbitrary ruling of the PD. One of the post I read regardless it is objective or not is that a resident has to repeat 6 months for one month of bad evaluation. The math and logic do not compute for me at all. For an instance, if I fail math only why would I retake physics? To mend discrepancy is what is important. All of these arbitrary remediation is a waste of ppl time. If I fail math, you'd be damn sure I will study as much math as I can to pass it instead of physics. This seems like a common sense to me.

I urge you all to circulate an email and write to ACGME. Terminated residents should get together and file a class action lawsuit against ACGME. You lost your jobs already and you need to get your careers back. A class action will be a collective lawsuit thus gives rise to more validity and also you will need no to worry about retaliation because only your names will appear and your previous residency programs will not know you have filed since the defendant will be ACGME. In addition, I believe that certain programs will be named numerous time if it is truly malignant therefore it will be difficult for PDs to even narrow down to any individuals. Yes you can hide in the masses. United we stand, right?

 

[theverdict]

Your proposal could be an improvement. But if an attending wants to fail a resident, he will do it across the board. A resident can have high in-service scores but still receive failing marks on fund of knowledge.

What we need is to require that evaluations must be filled by oath or affirmation, thus holding evaluators legally responsible. So if an attending states that a resident has no fund of knowledge, he could be held liable for fraud, if the resident demonstrates objectively fund of knowledge.

Right now the system is all discretion based. Discretion unfettered, much like in law, leads to abuse. It is human nature. Without an oath or affirmation, physicians can state whatever they want, whether or not there is any basis in fact.

Another important note is the recognition that residency training is not purely educational, thus a resident is not purely a student. There is a relationship here that is not present in any other traditional teacher-student relationship. In no other profession can a trainee bind the teacher in an agency relationship that could have legal implications. This relationship can become very arbitrary. Some attendings are very insecure and could see any shortcoming as possible malpractice when none is present. The bar for legal malpractice is high. In training, the bar is arbitrary. Thus not knowing some arcane differential could be construed as malpractice when the circumstances of the case suggest a horse rather than a zebra. In law, this reasoning would never pass summary judgment.

In addition, there is also a myth that the PD is responsible for the trainee after he leaves the program. To my knowledge, there has never been a program held vicariously liable for any malpractice committed by its graduates. Trust me, a lawyer would love for the opposite to be true. A major hospital system has deeper pockets than an individual attending. However many PDs hold this false notion. It gives them a "legitimate" reason to terminate residents whether deserved or not, with absolutely no basis in law.

But finally, ACGME needs to adopt due process rights. The right to an impartial hearing could save much money in the long run and help the resident realize that he has been treated fairly. However, the legal theories that could lead to adoption of due process rights require more legal scholarship to make a persuasive case given current case law. The Supreme Court has recently stated that residents are employees--thus making the reasoning less difficult. Nevertheless, the case involved was a matter of tax law not competency.

But the case was significant in that it rejected the traditional deference defense. As the traditional reasoning goes, doctors know medicine; lawyers know law; therefore, law should not interfere in the operation of medicine. I do not buy this argument. What advantage law has over medicine is its appreciation of reasoning and a greater capacity to understand the malevolence inherent in human nature. Law has competency to make decisions regarding medicine that definitely fall with its storied case law, its uncanny understanding of human nature. But I have no delusions as to law's weaknesses. It too has been a product of much malevolence. It too can represent the finest and worst of who we are as a people.

 

[RespectResident]

Verdict,

Thanks for taking the time to write down your thoughts but I believe there are few points I mentioned in my post was not understood so allow me to re-illiterate here.

First in response to your "if one attending fails you across the board, you will fail anyway," this is exactly what I am suggesting trying to prevent. By take a sum of all of the attendings who have ever evaluated you to determine whether you get your contract renewed should mathematically prevent an individual opinion deciding whether you get promoted or not. If your yearly average is stellar across the board with one exception, you should still get promoted. But if your average is below based on all of the evaluation you have receive throughout the year, then there are some heavy thinking you need to do. In fact, by adopting this system a resident can easily calculate how close to danger they are and exactly what they need to work on based on the score they receive. For an example, if I receive 2/5 on medical knowledge half way through the year then I will know for sure I need to study more. Period. And I need to bring up my game. On top of them, your score should be on a scale in comparison to your class peers. If all of the residents have bad scores with one particular attending then there is something to be said about that. For an instance, I have an attending to only give residents 3/5 including my chief who scores 97% in her PGY2. If adopting my system, her scores will obviously be lowered by this attending's evaluation but when on a scale she is average. And I do disagree with if one fails one core competency will not be continued is unfair. The six core competencies are nothing fantastical. They are qualities that any doctor should possess. Lacking one or another is not acceptable. Now it is inevitable a doctor will be better in one of the cores but he/she should have at least passing or above average score on all. A doctor can have a stellar medical knowledge but frauds and commit unethical acts, do you think this guy should be a doctor at all.

As for your comment about medicine and law do not mix I find this a bit troubling. Laws are created to keep orders in the society. It is a set of rule that we abide in order to have a functional body and this includes all walks of life including medicine. Laws are not only for malpractice lawsuits, it is a tool to assure everyone's rights are protected and in this case of the residents. This especially holds true in the United States. As much as doctors hate to admit to it, we also are under the covenants of the law. Not exercising our rights is unwise.

Now to address your comment about there is no precedence on laws holding accredited agency responsible for flawed system. This is not true. I cannot quote any particular cases but I am researching them right now. But just by logic this is a bit misleading. Perhaps the more correct way is "there is no precedence of holding accredited agency responsible in medicine." And this is why we need to start now. There are plenty of cases that a collective got together and hold a company responsible for a wrong doing because it's subsidiary company did something illegal. I believe years back there was an old lady who sue MacDonald for coffee being too hot and won the lawsuit. In this case the branch in fact the individual made the coffee too hot but the mother company who gives franchise rights to the local owner who hired that employee. It is not the local owner who was held accountable but the main entity. In the case of residency program, ACGME gives these programs a certificate to allow them to take on students. If this program is not meeting the expectation or abiding their contract then of course ACGME should take action. If they keep on receiving complaints about one program but not doing anything about it, I do feel that they need to be responsible.

ACGME does have due process but as I mention in my previous post, they are flawed. They require names and taking out the human elements of the process. Sure the department needs to abide those rules but how many residents actually have enough guts to go through it. Look at the posts on this forum, the ones who did go through with the process ended up even worse.

People. Write ACGME and circulate an email NOW. We need to protect our rights!!!! And please leave a response so we can all hear what you have to say. And if I am missing anything here, please correct/inform me as I would like to hear different opinions in order to come to a best solution to our pressing issue. Be well.

 

[RespectResident]

PDs are responsible for giving reference of all residents who have ever been in that program btw.

 

[NotAProgDirector]

My apologies in advance, this is probably going to be a long post.

Dear All,

I am here to propose to hold ACGME accountable for their lack of ability to protect residents when it comes to issues of dismissal/contract renewal.

The ACGME does not exist to protect residents. Is it a government entity funded by tax dollars to police GME? Nope. Is it funded via payments by residents to protect their interests? Nope. It's job is to accredit residency programs. They look at the big picture of a residency program, not at the granular issues of a singular resident.

A similar example would be the LCME which accredits medical schools in the US. If you fail out of a medical school you can call the LCME all you want, they don't represent students.

Based on their own policy which each program must abide in order to be accredited there are six core competencies that residents must demonstrate to excel. Each core should be weighted equally as lacking one is unacceptable to be a "good" physician. Thus medical knowledge should not be placed above morale behavior and vice versa. Thus, if one resident demonstrate to pass or above average throughout the year should be allowed to continue onto the next year or given the option of transferring to another residency program if subjective issues are at play.

Overall, I agree with this. You must be at least competent in all six competencies. Those that are get promoted.

This electronic evaluation system should be used for something instead of just a mere decoration. Why spends all these tax payers money when we don't even utilize it properly and to its fullest extent.

Whoa there. Exactly what "tax payer's money" are we talking about? The ACGME is funded privately and does not get any federal income. Their bduget comes completely from fees charged programs. You could argue that the "money" comes from taxes since taxes --> federal budget --> GME payments --> Hospital budgets --> GME budgets which pay the fees. But by that reasoning, my salary comes from taxes also (taxes --> medicare trust fund --> medicare payments to hospitals --> hospital budget --> Department funding --> my salary).

I'm also not certain what electronic system you're referring to. The ACGME does have an ePortfolio they are working on. Not sure how many programs are using it. Most of us use electronic eval systems that are private, that we pay with our own budgets.

It is a point system thus to calculate an above average performance is easy. This standardization will objectify one's performance throughout the year by attending who have actually worked with the residents instead of just one person's opinions.
... (lots of text removed to save space, read it above...
And let's face it. If a resident has across the board bad evaluation from all of the attending on different services the chances of them being competent in all six cores are slim. It's possible to receive a bad evaluation from a biased attending but it's another story to get bad evaluation from many.

What it sounds like you're suggesting is that we use only numeric evaluations to evaluate residents. Personally, I can't think of a worse idea. My experience with my own evaluation system is that numbers don't really help anyone. It's the comments that are helpful.

The suit filed by Nigro would have been easily prevented if such rule was followed. It would have saved the reputation of the PD and one million dollars from the hospital.

Really? The lawsuit you are referring to is this one. The result of said lawsuit was:

In November 2010, Nigro's suit was thrown out by a federal judge, who wrote in a memorandum opinion that Nigro had "produced no evidence contradicting the faculty's unanimous assessment that she possessed insufficient medical knowledge, insufficiently prioritized patient care ... and ultimately lacked the requisite commitment to the practice of medicine."

So I don't see any loss of money for the hospital, although they are now being sued again by her for inappropriate release of her medical records, again for $1 million. Perhaps they will lose that -- and if so, they deserve it. Sounds like she should have been fired for her performance, but they should not have access to her medical records regardless.

I feel that ACGME has this disbelief that the current system installed in their policy is working perfectly. They are working under the assumption that there is no retaliation and everyone is professional.

I agree with you that the grievence process in GME needs major improvement. It relies on an institution acting as a counterbalance to a program director, and we all know that model is flawed. The question is how. The best mechanism would be some sort of outside review board. This would be very expensive, as they would likely need to come to the program, review everything, etc. It seems only fair to me that residents share in the cost of this. How many would be willing to see deductions in their paychecks for something like this? I don't know.

It hard to argue with a number based on an entire performance, doesn't it?

That's a good point, that cuts both ways. If your score is too low, then you're fired. Your story doesn't matter. It makes no difference if you've shown improvement. Do you really want everything to come down to a number?

Plus, if I want to get rid of you I just have to ensure that you get enough low score evaluations.

They claim they have no authority to influence a PD decision but they certainly have authority to discredit a program immediately.

Really? So lets say that you're friend was let go, but you're still in the program. The program's accreditation is removed. You're let go as are all of the residents, and your career is over. Sound good?

If the resident has an overall passing scores (or above average scores) yet still face termination it should be ACGME's responsibility to find another position for this resident

This is a crazy idea. The ACGME is going to force some program to take you? How would they choose? You get to choose?

One of the post I read regardless it is objective or not is that a resident has to repeat 6 months for one month of bad evaluation. The math and logic do not compute for me at all. For an instance, if I fail math only why would I retake physics?

Usually, when a resident fails a rotation it comes on the heels of multiple months of borderline performance. hence, usually failing a block requires a longer term of remediation to get their skills up. If a failed block is truely an outlier, then I agree it deserves further scrutiny.

Your proposal could be an improvement. But if an attending wants to fail a resident, he will do it across the board. A resident can have high in-service scores but still receive failing marks on fund of knowledge.

What we need is to require that evaluations must be filled by oath or affirmation, thus holding evaluators legally responsible. So if an attending states that a resident has no fund of knowledge, he could be held liable for fraud, if the resident demonstrates objectively fund of knowledge.

This will only work with fund of knowledge and in service exams. Professionalism, Patient care, Interpersonal skills, etc will always be subjective.

Right now the system is all discretion based. Discretion unfettered, much like in law, leads to abuse. It is human nature. Without an oath or affirmation, physicians can state whatever they want, whether or not there is any basis in fact.

Agreed that some sort of check-and-balance is needed. Not sure that this is the best way. Suing for poor evaluations would be expensive and unlikely to be effective, as it's hard to prove.

In addition, there is also a myth that the PD is responsible for the trainee after he leaves the program. To my knowledge, there has never been a program held vicariously liable for any malpractice committed by its graduates. Trust me, a lawyer would love for the opposite to be true. A major hospital system has deeper pockets than an individual attending. However many PDs hold this false notion. It gives them a "legitimate" reason to terminate residents whether deserved or not, with absolutely no basis in law.

Agreed, this is baloney

But finally, ACGME needs to adopt due process rights. The right to an impartial hearing could save much money in the long run and help the resident realize that he has been treated fairly. However, the legal theories that could lead to adoption of due process rights require more legal scholarship to make a persuasive case given current case law. The Supreme Court has recently stated that residents are employees--thus making the reasoning less difficult. Nevertheless, the case involved was a matter of tax law not competency.

I agree that the best way to address this is via some sort of review. Whether employee due process is the right pathway is unclear.

For an example, if I receive 2/5 on medical knowledge half way through the year then I will know for sure I need to study more. Period. And I need to bring up my game.

If you make numbers the end-all-and-be-all of evaluations, PD's will just be certain that poor residents get lower scores.

On top of them, your score should be on a scale in comparison to your class peers.

Just want to point out that this is called "grading on a curve" and works both ways. If you get 3/5's and eveyone else gets 4/5's, you might get fired. Just like scaling up for tough graders, I would need to scale down for easy graders. This would ensure that someone gets fired every year, and that you were competing with your classmates not to be at the bottom.

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Look. I agree that the system needs to be fixed. Emailing the ACGME isn't going to do anything but make people mad and waste their time. Come up with a reasonable plan the ACGME could implement. How will this be paid for? It seems completely unfair to make programs pay for this entirely, so some of the cost will come from residents. I have no idea how expensive this all would be.

Really, what you're looking for a resident union. You are free to try to unionize the residents at any location, then they can negotiate for a contract with better terms for termination. Of course, then you pay union dues.

A simpler option would be to copy the grievence process from a unionized contract (like all of those in Canada, or the one's at BU) and try to get the ACGME to include some version of those in it's Program Requirements. That will be a political uphill battle, but could be done.

Or, you could allow this to go to the courts. That also is not free, but everyone gets to pay for their part. Personally I think the courts would make a big mess of all of this and wouldn't help.

 

[Old_Mil]

The annual residency exam is really the only objective standard of measure. That, and whether or not you have poor outcomes. If you don't have poor outcomes, and do well on your yearly exam objectively you're capable.

The best way to address the situation is to force a training program to write a check to the government restoring a terminated resident's funding (less what they have paid out in salary to the resident).

Having to write a check to CMS for a few hundred thousand dollars every time a resident is fired will give everyone involved pause and ensure only those who are a danger to patients are weeded out.

 

[SIZZLE11]

I absolutely agree with this. ACGME is not performing its real role. Most of the residency programs are taking benefits for this ACGME weakness.

 

[NotAProgDirector]

The annual residency exam is really the only objective standard of measure. That, and whether or not you have poor outcomes. If you don't have poor outcomes, and do well on your yearly exam objectively you're capable.

Exactly what outcomes should we measure?

Death rates? Length of stay? Patient satisfaction?

Should I let residents continue until they make a horrible mistake?

These are real questions. The ACGME wants us to move to an outcomes based assessment paradigm. I have trouble seeing what the outcomes are, other than the ones we already measure (i.e. subjective evaluations of clinical proficiency from a variety of sources -- faculty, peers, students, nurses, patients, etc)

The best way to address the situation is to force a training program to write a check to the government restoring a terminated resident's funding (less what they have paid out in salary to the resident).

Having to write a check to CMS for a few hundred thousand dollars every time a resident is fired will give everyone involved pause and ensure only those who are a danger to patients are weeded out.

This has been suggested before (perhaps by you?) and is not a completely unreasonable suggestion. But the devil is in the details.

We'd need to define "terminated" -- if a resident completes a PGY-1 and doesn't get a contract for a PGY-2, is that terminated? If you don't define it that way, programs will simply find a way to keep a resident until the end of their contract before letting them go. I think a reasonable compromise would be to not require a refund as long as the resident has a new program to go to -- that would incent programs to help residents with these transitions.

But what if a resident simply quits? Is it fair that I would lose funding for that? If you make an exception, programs will simply pressure residents to quit rather than be terminated.

This would almost certainly help decrease inappropriate terminations. However, it could have the (? unintended) effect of having programs continue residents who are truly not competent. Programs might decide that financially, they might as well keep someone on and simply graduate them.

It might also encourage programs to shrink -- simply not take risks on less competitive looking candidates. More people might be left without any program at all.

In any case, this is an idea that would be addressed outside of the ACGME. Funding is via Congress and Medicare, not the ACGME.

 

[Law2Doc]

...Terminated residents should get together and file a class action lawsuit against ACGME. You lost your jobs already and you need to get your careers back. A class action will be a collective lawsuit thus gives rise to more validity and also you will need no to worry about retaliation because only your names will appear and your previous residency programs will not know you have filed since the defendant will be ACGME. In addition, I believe that certain programs will be named numerous time if it is truly malignant therefore it will be difficult for PDs to even narrow down to any individuals. Yes you can hide in the masses. United we stand, right?

Um no -- the LAST thing you want to do is unite. Honestly, for every 1 person who believes they were unfairly terminated and have a legitimate gripe, there are probably several who should have been terminated. So the last thing you want to do is hitch your wagon to someone else's sinking ship. If you were unfairly terminated, that's awful, but you aren't going to fix it by linking yourself to the dude who was a real danger to his patients. We all know someone whose contract was not renewed, and most of the time it's not someone who just caught a bad break. This is not the person you want in your "class action" suit. You don't want to be considered similarly situated with such a person, because that dooms you. You absolutely want to stand alone because if you have a legitimate gripe, that is going to be ignored in a group of less deserving folks.

 

[Gordon Sims]

Um no -- the LAST thing you want to do is unite. Honestly, for every 1 person who believes they were unfairly terminated and have a legitimate gripe, there are probably several who should have been terminated. So the last thing you want to do is hitch your wagon to someone else's sinking ship. If you were unfairly terminated, that's awful, but you aren't going to fix it by linking yourself to the dude who was a real danger to his patients. We all know someone whose contract was not renewed, and most of the time it's not someone who just caught a bad break. This is not the person you want in your "class action" suit. You don't want to be considered similarly situated with such a person, because that dooms you. You absolutely want to stand alone because if you have a legitimate gripe, that is going to be ignored in a group of less deserving folks.

Very good counterpoint L2D.

 

[dragonfly99]

I actually don't personally know anyone well who has been canned. I know one person who got his training extended and IMHO it was very silly and the person was NOT incompetent, but just wasn't good at playing departmental politics. However, the place where I do fellowship has apparently fired several people from IM over the years, and I can think of at least 1 intern and 1 resident who should be fired if they don't clean up their acts....

 

[Doctor Bagel]

I actually don't personally know anyone well who has been canned. I know one person who got his training extended and IMHO it was very silly and the person was NOT incompetent, but just wasn't good at playing departmental politics. However, the place where I do fellowship has apparently fired several people from IM over the years, and I can think of at least 1 intern and 1 resident who should be fired if they don't clean up their acts....

What type of stuff are they doing? My program is losing someone, and I know I have absolutely no right to know any details, but I'm wondering what type of stuff causes a resident to get fired other than the totally obvious (showing up drunk, missing work, being abusive, etc.). We're honestly not expected to have a whole lot of competence early in our training.

 

[Law2Doc]

What type of stuff are they doing? My program is losing someone, and I know I have absolutely no right to know any details, but I'm wondering what type of stuff causes a resident to get fired other than the totally obvious (showing up drunk, missing work, being abusive, etc.). We're honestly not expected to have a whole lot of competence early in our training.

From what I've seen, it's usually things like repeatedly claiming you did or checked things you didn't, misrepresenting things to attendings, effectively being unwilling to say "I don't know" when it's the truth. Also not being a team player such that the chiefs have negative things to say about you at every review, or having multiple nurses report that you never answered their pages each overnight, can make the program not give you that contract renewal. It's not usually the totally obvious kinds of things you describe, although those could certainly get you in trouble. And it has less to do with not being competent from day one, and more an issue of not being able to do the very basic things after being repeatedly shown and asked to do things a certain way. Some people are simply found not to be reliable or honest. You can sometimes BS your way through med school with these traits, but in residency, it's harder.

The couple of people I've come across who haven't had contracts renewed reportedly were given many chances to shape up, but the same issues kept coming up. I'm sure there are folks who have legitimate gripes for being let go, but they really don't serve themselves well by "uniting" with the crowd I'm describing (who, I'm sure, also believe, incorrectly, that they were wronged).

 

[ShyRem]

I do know someone who was fired, and it was absolutely warranted. The resident was given many opportunities to rectify their issues (and no there was no depression/abuse, alcohol or drug dependence - it was all competence) and yet failed to do so and in fact argued they were not at all incompetent to anyone who would listen.