residency termination

[forbes270]

I have been following this forum for quite sometime, and knew some input from experienced folks here would be vital in my quandary.

With a profile 85/77/pass/81(3 attempt), made it to Family Medicine residency in July 2005 on J1 visa. I did not realise how technical ObGyn was in this field, and with absolutely no experience I started having trouble in residency particularly in the Ob department. Once there was an instance where my PD thought I lied to him about a physical finding, but they decided to keep me on intense probation for 4 months to decide upon my internship year.

I performed well (with meek submission) and they were very happy to let me into second year, though extended my residency by 6 months saying I am raw and need more experience overall. Second year was without much issues in any department.

At the beginning of my third year, my PD being happy with my in-training scores and overall performance; gave me a good letter for my perspective job and j1 waiver application. That process even started with the USCIS.

Then I had to do my ObGyn rotation again. I was doing it after a 15 months gap, again faltered, and once in a heat of the moment, I wrote a fetal heart rate (FHR)value which I had not performed on a patient. Later on, the attending physician was called by the patient saying no one checked the FHR. Nonetheless, the patient and baby had an uneventful episode and they returned home.

My PD got vindictive, hell broke loose, and saying I had been warned about this event before in residency, suspended me. Within 2 weeks, I was terminated with nothing but 6 months of mere electives left.

The reason as they technically worded it was "falsification of medical records". I tried to avail any residency openings, but no one gave me an interview after reading my email where I openly declared my termination. Being on J1, I also had to leave the country in 30 days.

I do not want to stir emotions, but I kept asking the GME about trying to decrease the impact of punishment as it hits me for life, not just that particular moment. My PD told me we would be happy to recommend and say to others that give him a a second chance in IM... but not FP.

The main problem is that Pennsylvania medical board will not issue me a certificate of good standing, as I was terminated from residency. Had I voluntarily resigned during the 2 weeks i was suspended, i could retrieve my situation a mere bit, as my good standing would stay.

How can I alter my character assassination?? I am ready to take any path however hard or long to get back to the US and perhaps practise medicine, but how?? I heard of people practising without completing residency, I checked a couple of licensing boards in the US which give license with just internship completion, but I do not have the CERTIFICATE OF GOOD STANDING, which they require.

If anyone can spring up something that I have falsely assumed or do not know, you may help me get my life back. Its been the worst 9 months of my life post termination, and I do admit my mistake and believe that it is in my hands to turn it around, and all I need is an opportunity.

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[SouthernSurgeon]

Not to get on too much of a soapbox here, but you were twice called out by your PD for falsifying exam findings - including skipping out on one of the most noticeable parts of a pregnant well-check up. Hard to see where the "character assassination" claim is coming from; especially when the PD is offering to help you get into another field.

Also, you seem to use your lack of familiarity with OB/Gyn as an excuse; while that makes it understandable that you might forget to check FHR, it does not explain why you falsified the records.

 

[dragonfly99]

They fired you because you lied on the medical records. I realize you probably just were very scared and freaked out, but you could have harmed the patient or her baby. That is the point. I'm sure doing ob/gyn with no prior experience was very challenging.

I think you will not get a license in any state having been fired from your previous residency and not being held in good standing currently.

I think it will be hard for you to get back into any US residency. However, if you want to try, it needs to be some field that doesn't have obstetrics, and hopefully not gyn. Internal medicine has some gyn...have to do pap smears and breast exams...but there isn't really any obstetrics.

I think you should pick a new specialty to aim for...maybe pathology, or physical medicine/rehab, and then try to talk with your old program director, tell him that you know you made a serious mistake, but you regret that a lot and you realize that you weren't good at ob/gyn and you want to try again at another specialty that doesn't do any ob/gyn stuff. If you want you can try internal medicine but I discourage that because it's really pretty similar to family practice, except no peds and fewer pregnant women.

You probably need to go somewhere outside of Pennsylvania as well.

I think you'll have a hard time getting back into the US though...may need to try a different country, like your home country, Australia, etc.

Good luck.

 

[DrMom]

How can I alter my character assassination??

You falsified medical records, potentially risking an unborn child. You did this after having similar issues in the past.

Being reprimanded for this is *not* character assassination. If you're doing things like this when you know that someone is monitoring you, it makes it extremely concerning for how you will behave as an independent physicians out on your own.

You've gotten some valuable advice in the post above from dragonfly. I recommend that you take the advice, but you're going to also have to acknowledge that your actions directly and appropriately led to the consequence you're currently dealing with before you're likely to be successful in moving on in this endeavor of continuing your training in the US.

 

[McGillGrad]

I sense a dogpile forming so I will only say that this is a crappy situation for you.

You're toast for anything reasonable, but you could probably try VA hospitals. They need people badly.

 

[Law2Doc]

...
How can I alter my character assassination??...

As others have stated, this isn't a character assassination, it's a self inflicted wound. You don't seem to get that falsifying records is a VERY big deal. From your post it sounds like you already got a second chance after being accused of something similar. The issue isn't whether it worked out alright for this family, the issue is that it might not have -- you exposed the child in this case to risk and you exposed the hospital to indefensible liability. A medical record is a legal document. Falsifying records is enough to get you fired in any field, but particularly in medicine where lives are at stake. So you have to own up to the fact that you screwed up, not try and act like a victim (being character assassinated, or having your career unfairly damaged); you and you alone put yourself into this boat, and countless other residents seem to be able to get by every year throughout the country without falsifying things. Once you "get" that you screwed up, it might be possible to beg forgiveness for screwing up and maybe someone, somewhere will give you a second chance. But no more passing the buck, no more blaming having to do OB on something that had nothing to do with that specialty and everything to do with not owning up to an oversight. Sorry to be harsh, but your post was less about "what do I do now after I screwed up" and comes across more like "how do I keep from being assassinated". Until you get that it's the former and not the latter, it will be very hard for folks to take you seriously as a professional.

 

[exPCM]

You seem to think you should get another chance. Maybe you will and maybe you won't. For your sake I hope you do get a second chance.
However second chances are not mandatory in life. If I get drunk and then drive and then kill somebody then I will not expect to get a "second chance" but I expect I will end up in jail. Now it is true you did not kill anybody but you must realize that we do not always get second chances. With this in mind I always tell people to make the most of their first opportunity.
Good luck and I suggest following the sage advice of dragonfly99.

 

[LilJon]

As the foo fighters said.."Its times like these you learn to live again.."

I am also working on my second chance at residency and medicine. My situation is a little different from yours. The only thing I can say to you is continue to follow your dreams. I know you probably feel like crap. There is probably alot of shame and anger at yourself too. Dont let anyone tell you that you cannot bounce back. Find a new path. Your path is still out there but youre gonna have to overcome your situation, find a new way and pursue it. For me that process took a long time. I can tell you from the outset alot of people told me I was done and there were alot (many more acutally)of people that told me what I im telling you..continue walking. It took me a while (almost a year) to take some self inventory, figure out what changes I needed to make with me and then figure out where I go from here.

Everybody makes mistakes. Anyone who tells you they are perfect and has lived a perfect life is either lying to themself or they havent lived long enough. There are people out there who realize this and will give you a second chance but they are not going to find you while your wallowing in your guilt and shame, you will have to do your own growing from this and then step out and find them. I started the match process this year thinking that no one would give me a second chance. Then the miracle happened..i got an interview. By the time it was all said and done I had way more than I could attend. My situation took a job from me but I gained so much personal growth that I almost shutter to think about where I would be if I had not had to endure it. There is hope.

 

[Law2Doc]

As the foo fighters said.."Its times like these you learn to live again.."

I am also working on my second chance at residency and medicine. My situation is a little different from yours. The only thing I can say to you is continue to follow your dreams. I know you probably feel like crap. There is probably alot of shame and anger at yourself too. Dont let anyone tell you that you cannot bounce back. Find a new path. Your path is still out there but youre gonna have to overcome your situation, find a new way and pursue it. For me that process took a long time. I can tell you from the outset alot of people told me I was done and there were alot (many more acutally)of people that told me what I im telling you..continue walking. It took me a while (almost a year) to take some self inventory, figure out what changes I needed to make with me and then figure out where I go from here.

Everybody makes mistakes. Anyone who tells you they are perfect and has lived a perfect life is either lying to themself or they havent lived long enough. There are people out there who realize this and will give you a second chance but they are not going to find you while your wallowing in your guilt and shame, you will have to do your own growing from this and then step out and find them. I started the match process this year thinking that no one would give me a second chance. Then the miracle happened..i got an interview. By the time it was all said and done I had way more than I could attend. My situation took a job from me but I gained so much personal growth that I almost shutter to think about where I would be if I had not had to endure it. There is hope.

The difference between your post and OPs is that you seem to be owning up to the mistakes much more, feeling "guilt", "shame", and that makes you much more ready for a second chance. When you are still openly blaming others for "character assassination" or being "vindictive", as the OP has done in the above post, it's less clear that he is acknowledging being totally to blame for his actions (which, reading his post actually seem pretty indefensible to most of us, and not something "everybody does"). Until OP is ready to say (and truly believe) "I screwed up, nobody is being vindictive or doing anything to me, I did it to myself and I'm ashamed of what I've done", it is very hard for anyone to get excited to give him/her a second (third?) chance.

 

[forbes270]

Well as some of u have commented, all I needed was some direction as to start my remedial process... because I still enjoy medicine and want to prove to myself I am capable of doing it the way it should be done.

Actually I have a friend in Harlem,NY who told me this is very common in NY and people have managed to resume residency as second chances in IM. Thats what started my thinking process.

I do have this limitation of low scores, but the LORs from my program are very strong. I appreciate everyone's $0.02 and will continue to look for fresh ideas and thoughts....on how to get a PD to keep the faith!

 

[Winged Scapula]

I find the above response very odd.

Did you actually read the responses to your query?

The issue is *not* your "low scores" or that you have "good letters" from your program but that you were terminated. For lying. More than once.

People DO get terminated from residency, your friend in NY is correct. But there's a HUGE difference between someone who gets terminated for lack of clinical skills, fund of knowledge, and someone who gets terminated for lying. The two former reasons can be rectified, I'm not sure the latter can. I'm not a PD but I'd find it difficult to take on as a resident unless I really was just looking for a warm body and didn't care about any potential liability.

 

[maceo]

all i can say is get yourself a lawyer and sue these guys.

If you wrote down fetal heart tracing you probably checked it without realizing it. Did anyone see you examine the patient? I would fight this tooth and nail.. seriously.

 

[Law2Doc]

all i can say is get yourself a lawyer and sue these guys.

If you wrote down fetal heart tracing you probably checked it without realizing it. Did anyone see you examine the patient? I would fight this tooth and nail.. seriously.

Um no. He said explicitly in his prior post "I wrote a fetal heart rate (FHR)value which I had not performed on a patient.". So no he didn't check it without realizing it. He didn't check it and does realize that fact. He just isn't owning up to the fact that this is a very big deal (falsifying a medical record). If your post is suggesting he compound the problem by now lying in court that he in fact did do something he didn't do, that is a very bad idea. And not one becoming of a professional. No lawyer would put forth testimony that they know is a lie, so he'd have to lie to his lawyer too. When will it end? The answer is not more lies. Lying is what put him in this mess, and it is indefensible. The answer is to own up to it, understand why it was wrong, stop passing the buck by accusing folks of trying to assassinate his character. And maybe somebody will give him another chance. But to even suggest to further the unethical behavior by going on a lying spree in court is eyebrow raising and appalling. Bad bad idea. seriously.

 

[tibor75]

For one, I hope you are not successful because I can't imagine somebody who falsifies records repeatedly as a physician in this country. Try government work.

 

[maceo]

Um no. He said explicitly in his prior post "I wrote a fetal heart rate (FHR)value which I had not performed on a patient.". So no he didn't check it without realizing it. He didn't check it and does realize that fact. He just isn't owning up to the fact that this is a very big deal (falsifying a medical record). If your post is suggesting he compound the problem by now lying in court that he in fact did do something he didn't do, that is a very bad idea. And not one becoming of a professional. No lawyer would put forth testimony that they know is a lie, so he'd have to lie to his lawyer too. When will it end? The answer is not more lies. Lying is what put him in this mess, and it is indefensible. The answer is to own up to it, understand why it was wrong, stop passing the buck by accusing folks of trying to assassinate his character. And maybe somebody will give him another chance. But to even suggest to further the unethical behavior by going on a lying spree in court is eyebrow raising and appalling. Bad bad idea. seriously.

would you relax? He didnt lie if you asked him if he cleaned the latrines and he said yes when he didnt

i once saw a optho in the icu write fundus normal disc sharp on a patient with a glass eye

i see nurses and doctors constantly write no murmurs rubs or gallops and they dont even have a stethoscope..

the point is, this is NOT a reason to terminate someone from a program thats for sure. especially if there was NO bad outcome.

 

[SouthernSurgeon]

He didnt lie if you asked him if he cleaned the latrines and he said yes when he didnt

huh?

 

[silas2642]

would you relax? He didnt lie if you asked him if he cleaned the latrines and he said yes when he didnt

i once saw a optho in the icu write fundus normal disc sharp on a patient with a glass eye

i see nurses and doctors constantly write no murmurs rubs or gallops and they dont even have a stethoscope..

the point is, this is NOT a reason to terminate someone from a program thats for sure. especially if there was NO bad outcome.

Are you being serious? Are you a real attending or a troll? The entire medical system is, or should be, built on trust-- patients trust their physicians to do what is best for them and to make medical decisions that are in their best interests; attendings need to trust that when they ask their residents to do something that they're going to do it and when they don't do it, that they're not going to falsify legal documents and lie about it. Just because people are dishonest and lie doesn't mean that they should.

You may see nurses and doctors who are constantly writing "no murmurs, rubs or gallops" who don't have a stethoscopes, but that doesn't mean they didn't have one on when they were seeing the pt a moment ago.

From a pt's perspective, I wouldn't want a physician touching me or my grandmother with a ten foot pole who is running around falsifying legal documents after he has neglected to do what he is supposed to do and then won't take responsibility for it. Especially when it's something as basic as taking a FHR-- a med student should probably know how to do that, much less a 3rd year FP resident.

 

[Winged Scapula]

I agree with maceo that "chart doctoring" is widespread.

We've probably all had experiences where inaccurate information is passed on from note to note (ie, "chest normal" when the patient has a fungating mass sitting on their upper sternum, but doctor #1 didn't examine it, and every one else writing notes afterwards just copies his note - real example I've seen).

I've seen notes which were taken almost verbatim from the consult (early in my career I used the Queen's English much more, so it was easy to pick out who was "pinching" my consult to flesh out their H&P).

I disagree with maceo that this is not a reason to terminate the resident. Especially when its happened twice.

 

[DarthNeurology]

I agree with maceo that "chart doctoring" is widespread.

We've probably all had experiences where inaccurate information is passed on from note to note (ie, "chest normal" when the patient has a fungating mass sitting on their upper sternum, but doctor #1 didn't examine it, and every one else writing notes afterwards just copies his note - real example I've seen).

I've seen notes which were taken almost verbatim from the consult (early in my career I used the Queen's English much more, so it was easy to pick out who was "pinching" my consult to flesh out their H&P).

I disagree with maceo that this is not a reason to terminate the resident. Especially when its happened twice.

I saw a resident when I was a student make-up a physical examination of a patient as she wrote down the whole regular rate and rhythm etc . . . and did not lay a hand on the patient! Maybe I should have "reported" her, my jaw just dropped. She thought it was a "b.s." consult, but still I would have examined the patient, and did for my note, . . . It doesn't take that long to do a focused physical, i.e. 5 to 10 minutes, makes no sense to make it up? Especially since the note is your way of following the patient based on how you do a physical exam findings, I don't trust others to do the same exam I do.

What did/do you do Winged if someone copies your consult physical? I.e. do you report them, talk to them or just roll your eyes?

 

[dragonfly99]

Chart doctoring happens a lot, and people cut and paste too much in both consults and daily notes.
However, not checking the FHR on a laboring woman is a serious case of not DOING something that could have had important consequences.

 

[Winged Scapula]

Chart doctoring happens a lot, and people cut and paste too much in both consults and daily notes.
However, not checking the FHR on a laboring woman is a serious case of not DOING something that could have had important consequences.

Exactly, which is why I disagree with maceo.

Its one thing to copy a patient's history from another note, its quite another to document you did something (that you didn't) which may have serious repercussions for a patient.

Darth...its a difficult situation when you find another physician copying your work. When I've found myself in that situation, I did one of a few things:

- if it was a subordinate, ie, my intern or medical student, I made a gentle comment to them that they should be careful because it "appears" that they are copying other's work
- if it was a colleague, I'd probably say nothing unless it was someone I could really feel comfortable with
- if it was a colleague's subordinate, I'd say something to them

I'd love to say I was always on the side of good and moral right, but let's face it, its hard to confront people, especially colleagues and to do it in a way which would be well received.

I used to see this more on medicine than surgery, probably because of the volume of admits and length of the notes they had to write.

 

[maceo]

Are you being serious? Are you a real attending or a troll? The entire medical system is, or should be, built on trust-- patients trust their physicians to do what is best for them and to make medical decisions that are in their best interests; attendings need to trust that when they ask their residents to do something that they're going to do it and when they don't do it, that they're not going to falsify legal documents and lie about it. Just because people are dishonest and lie doesn't mean that they should.

You may see nurses and doctors who are constantly writing "no murmurs, rubs or gallops" who don't have a stethoscopes, but that doesn't mean they didn't have one on when they were seeing the pt a moment ago.

From a pt's perspective, I wouldn't want a physician touching me or my grandmother with a ten foot pole who is running around falsifying legal documents after he has neglected to do what he is supposed to do and then won't take responsibility for it. Especially when it's something as basic as taking a FHR-- a med student should probably know how to do that, much less a 3rd year FP resident.

get off of your soap box

the resident should not have been terminated for this and no record of it should have been placed about this in his/her file. I agree he /she did something wrong. Pull him aside make him feel really small about what he/she did. give him hell about it. BUt dont write it in the file. These are things that truly destroy peoples careers. Its just overly dramatized> I see respected physicians like i said earlier fudge physical exam findings. serious errors. Its just sooo rampant its not even funny. SO you as a medical student have absolutely NO business judging anybody who is a resident. WHen you get to that stage maybe, but not now. GO back to allopathic section.. Get off of your soap box and your high horse.

 

[McGillGrad]

How many errors (that potentionally places the patient in jeopardy) does one need to committ before being dismissed? Two is apprently not enough for you. Three, four, five? How many?

get off of your soap box

the resident should not have been terminated for this and no record of it should have been placed about this in his/her file. I agree he /she did something wrong. Pull him aside make him feel really small about what he/she did. give him hell about it. BUt dont write it in the file. These are things that truly destroy peoples careers. Its just overly dramatized> I see respected physicians like i said earlier fudge physical exam findings. serious errors. Its just sooo rampant its not even funny. SO you as a medical student have absolutely NO business judging anybody who is a resident. WHen you get to that stage maybe, but not now. GO back to allopathic section.. Get off of your soap box and your high horse.

 

[silas2642]

get off of your soap box

the resident should not have been terminated for this and no record of it should have been placed about this in his/her file. I agree he /she did something wrong. Pull him aside make him feel really small about what he/she did. give him hell about it. BUt dont write it in the file. These are things that truly destroy peoples careers. Its just overly dramatized> I see respected physicians like i said earlier fudge physical exam findings. serious errors. Its just sooo rampant its not even funny. SO you as a medical student have absolutely NO business judging anybody who is a resident. WHen you get to that stage maybe, but not now. GO back to allopathic section.. Get off of your soap box and your high horse.

Uhh... I'm not standing on a soap box because this isn't gray situation here. This isn't a situation where we're saying, "oh, I can see where he might have gone wrong." He messed up, bigtime, TWICE. He falsified a legal document, put a patient at risk, TWICE. You don't get to come back from that, especially when you don't even see the problem-- he doesn't even accept responsibility for his actions. That's not a good sign. I may be just a medical student, but I'm not so stupid and naive as to not see that this guy should not be around pregnant women and can't really be trusted.

 

[DarthNeurology]

Exactly, which is why I disagree with maceo.

Its one thing to copy a patient's history from another note, its quite another to document you did something (that you didn't) which may have serious repercussions for a patient.

Darth...its a difficult situation when you find another physician copying your work. When I've found myself in that situation, I did one of a few things:

- if it was a subordinate, ie, my intern or medical student, I made a gentle comment to them that they should be careful because it "appears" that they are copying other's work
- if it was a colleague, I'd probably say nothing unless it was someone I could really feel comfortable with
- if it was a colleague's subordinate, I'd say something to them

I'd love to say I was always on the side of good and moral right, but let's face it, its hard to confront people, especially colleagues and to do it in a way which would be well received.

I used to see this more on medicine than surgery, probably because of the volume of admits and length of the notes they had to write.

The resident actually didn't copy my work, she made up a whole fictious physical exmination because she thought it was a bogus consult! She sure didn't read my note as I hadn't examined the patient, yet, nobody had, it was a consult. I didn't feel as a subordinate I should/could complain, she could say that she examined the patient, but that didn't happen as we were together seeing the patient for the first time. I would definitely tell a fellow resident not to do this . . . between colleagues is better.

 

[Law2Doc]

I agree with maceo that "chart doctoring" is widespread.

We've probably all had experiences where inaccurate information is passed on from note to note (ie, "chest normal" when the patient has a fungating mass sitting on their upper sternum, but doctor #1 didn't examine it, and every one else writing notes afterwards just copies his note - real example I've seen).

I've seen notes which were taken almost verbatim from the consult (early in my career I used the Queen's English much more, so it was easy to pick out who was "pinching" my consult to flesh out their H&P).

I disagree with maceo that this is not a reason to terminate the resident. Especially when its happened twice.

Chart doctoring may be widespread (but that's never a defense), but putting down a number you didn't check is falsifying medical records, and yes, it can subject the hospital to very real and very large liability and thus does merit stern discipline and potentially a firing, particularly if someone gets caught twice. It is indefensible to put something in the chart you didn't check. Sure nurses do it way too frequently, particularly in terms of things like respiratory rate. And too many doctors will jot down things like CN II-XII intact even though they perhaps only checked a handful. But if you are going to take these shortcuts, you have to know there are potential consequences. So most people will only be more cavalier about the things that don't matter, like an eye exam on a patient with a foot trauma. As mentioned in an OBGYN case there will be a handful of things that you HAVE to check, and FHR is going to be one of them. That's not the same at all. That's faking the whole reason you are seeing the patient.

 

[Winged Scapula]

Just to clarify:

I don't think I ever said that chart doctoring was the same was what the OP did which was to actively falsify medical records, twice, and in the case of where it was a significant factor in that patient's care. Seems several people think that's what my posts stated. I was agreeing with maceo that it happens and disagreeing with him that the OP doesn't deserve what he got.

 

[Winged Scapula]

The resident actually didn't copy my work, she made up a whole fictious physical exmination because she thought it was a bogus consult! She sure didn't read my note as I hadn't examined the patient, yet, nobody had, it was a consult. I didn't feel as a subordinate I should/could complain, she could say that she examined the patient, but that didn't happen as we were together seeing the patient for the first time. I would definitely tell a fellow resident not to do this . . . between colleagues is better.

That's an unfortunate situation.

We've probably all had consults we thought were bogus only to have them turn out not to be.

Its one thing to copy someone else's work, its another altogether to falsify the record (ie, make up a PE). That's really beyond the pale - bogus consult or not.

Its times like those when you really wish the patient had some sort of obvious physical defect for which the perp could be caught (the old medical school story of the amputee and the intern who wrote distal pulses palpable, extremity warm and well perfused with good ROM).

 

[PeepshowJohnny]

We had a situation third year where an intern made a mistake being described above. They fired off a quick, routine physical exam finding they hadn't checked ont he patient as habit, when it turned out it was abnormal.

The attending was pretty magnanimous about it (It's different from the above situation because it was a chronic problem and not something that'd probably affect care) but gave us a nice talk about it. Basically it boiled down to, if you miss a finding in a patient, that's bad. But the only thing worse is DOCUMENTING you checked for it when you didn't.

For example, 63 year old man comes in with low back pain. Physician doesn't do a prostate exam, but it turns out this guy has prostate cancer that's gone to bone that would be immediately apparent had he done it. Now, this doc is in trouble already. But if he'd gone through and said that he'd done a rectal exam when he hadn't (or even just dictated "physical exam normal") he'd in a much worse situation than if he just documented what findings he did do.

 

[Abram Hoffer]

The confusing part for a rookie (read: 4th yr med student/intern) is to know how much is enough. If a particular exam seems pertinent, it is normally done. But it is not until one writes a note/dictates an H&P (possibly far-removed from the patient locale) that the rookie realizes s/he should have done this or that. Then the question becomes, go back and do it? Use someone else's findings? Make it up? How much time do you have? Are you already far behind? The temptation is there sometimes.

I cannot tell you how many times I have seen an attending flat out make things up. They even write their note before they see the pt and say, "Oh yeah, let's go say hi to that pt." Perhaps insurance companies and their "requirements" are to blame; things such as putting ROS negative except as noted in the note mean that you did a complete and thorough review of systems--otherwise, they won't reimburse. Clinically, you know, quite often, that you don't need to examine certain parts of the body with certain conditions.

 

[Doowai]

I am heartened to see so many who feel honest charting is so important - even on the seemingly small and inconsequential things.

unfortunately I learned many years ago that often those who protest the strongest are the guiltiest. 20 years ago , my second job in my previous healthcare occupation had , what was for me a hefty salary. I was so happy to have that well paying job. Then I found out my employer was falsifying MY records for insurance purposes. I quit and blew the whistle to those who should have done something professionally. I did not realize how well connected my former employer was. One guy in particular reacted soooo strongly when I told him what my employer had done saying things literally like "How can YOU live with yourself..." - when I found out he had gone running to my employer afterwards to cause me problems I learned a great lesson. My former employer did some prison time a couple of years later - so I was really glad I left when I did, - I look really bad in orange, hate picking up trash on the side of the road with chain gangs, and don't like bunkmates called Bubba.

Falsifying medical records is all kinds of illegal - as well as being hazardous to patients and being ethically wrong. Your PD could be legally liable (not just malpractice liable) by knowingly tolerating falsifying records. As in FBI OIG investigation, being barred from Medicare etc, spending time in prison etc. This is not soapbox morality - its the fact that medical records used for insurance billing become serious crimes when falsified

 

[Law2Doc]

The confusing part for a rookie (read: 4th yr med student/intern) is to know how much is enough. If a particular exam seems pertinent, it is normally done. But it is not until one writes a note/dictates an H&P (possibly far-removed from the patient locale) that the rookie realizes s/he should have done this or that. Then the question becomes, go back and do it? Use someone else's findings? Make it up? How much time do you have? Are you already far behind? The temptation is there sometimes.

I cannot tell you how many times I have seen an attending flat out make things up. They even write their note before they see the pt and say, "Oh yeah, let's go say hi to that pt." Perhaps insurance companies and their "requirements" are to blame; things such as putting ROS negative except as noted in the note mean that you did a complete and thorough review of systems--otherwise, they won't reimburse. Clinically, you know, quite often, that you don't need to examine certain parts of the body with certain conditions.

"Make it up" is always the wrong answer. I think that's the learning point that can be gleaned from the OP's situation. Your only choices are go back and do the part of the exam you missed, or leave it blank on the form and be completely candid when asked about it. If OP did either of these, he would not have been terminated. Since most hospitals can't bill as much if you aren't able to complete the whole H&P, most places would want you to go back and pick up the spare. But because of liability involved, nobody is going to tolerate falsifying records. To the extent it is "widespread" it just means that risk management doesn't know about it YET, and a lot of people are risking their jobs every time they pick up a pen. But once a hospital knows about it, they have to do something, because as Doowai suggests in his last paragraph, if you as PD have a resident who is behaving negligently and you KNOW about it, you too might be liable for negligent supervision.

 

[maceo]

Uhh... I'm not standing on a soap box because this isn't gray situation here. This isn't a situation where we're saying, "oh, I can see where he might have gone wrong." He messed up, bigtime, TWICE. He falsified a legal document, put a patient at risk, TWICE. You don't get to come back from that, especially when you don't even see the problem-- he doesn't even accept responsibility for his actions. That's not a good sign. I may be just a medical student, but I'm not so stupid and naive as to not see that this guy should not be around pregnant women and can't really be trusted.

How did he put anyone at risk? The fhr were normal. the patient did well where did he put someone at risk?

 

[McGillGrad]

How did he put anyone at risk? The fhr were normal. the patient did well where did he put someone at risk?

He put the patient at risk by not taking the FHR and writing on the record that he did. What is the FHR was not normal and the baby had complications?

 

[maceo]

"Make it up" is always the wrong answer. I think that's the learning point that can be gleaned from the OP's situation. Your only choices are go back and do the part of the exam you missed, or leave it blank on the form and be completely candid when asked about it. If OP did either of these, he would not have been terminated. Since most hospitals can't bill as much if you aren't able to complete the whole H&P, most places would want you to go back and pick up the spare. But because of liability involved, nobody is going to tolerate falsifying records. To the extent it is "widespread" it just means that risk management doesn't know about it YET, and a lot of people are risking their jobs every time they pick up a pen. But once a hospital knows about it, they have to do something, because as Doowai suggests in his last paragraph, if you as PD have a resident who is behaving negligently and you KNOW about it, you too might be liable for negligent supervision.

You are a medical student. I dont know what stage you are at but sounds pretty early. YOu cant judge someone especiall in medicine unless youve been there. You dont know what being an intern is. you have no idea. You dont know the time pressures and the sheer volume that the intern has to pick up. They are gonna make mistakes and certainly this one is a minor one that does not merit firing. He/ she is there to learn. I dont give a rats arse about your legal backround. I really dont. Lawyers are what is wrong with the system. I would go under oath to say I wouldnt terminate this person.

 

[forbes270]

I do realise what i did put someone's unborn life at risk, accept my termination, will take all the scum hurled at me, but all I ask is for a process of remediation and if I can survive that, let me continue. If I fail, I quit. Surely there has to be some path to tread upon...

 

[silas2642]

You are a medical student. I dont know what stage you are at but sounds pretty early. YOu cant judge someone especiall in medicine unless youve been there. You dont know what being an intern is. you have no idea. You dont know the time pressures and the sheer volume that the intern has to pick up. They are gonna make mistakes and certainly this one is a minor one that does not merit firing. He/ she is there to learn. I dont give a rats arse about your legal backround. I really dont. Lawyers are what is wrong with the system. I would go under oath to say I wouldnt terminate this person.

How is not taking a FHR on a woman in labor, documenting in her chart that you did, after you've been caught doing the same thing before 2 years ago a minor incident? This isn't an intern or a medical student we're talking about, and even if it was an intern, this was a 3rd year FM resident who had made the same mistake beofre.

Law2Doc can judge and so can others because that could have been her baby and that could have been mine. You may not give a rat's arse about her law background, but guess what-- a patient who is in labor doesn't really care how tired their physician is or how overworked he/she is, or how many patients they have to see. They expect to receive a standard test like a goddamned FHR to make sure their unborn child is doing okay. We went into medicine for the patients, remember?

You can't document what you didn't do, you should document what you did do, because if you don't, it never happened. Period. These are legal documents we are talking about-- they hold up in court.

 

[Winged Scapula]

While I understand why a lot of people have stated their no tolerance policy with regards to this, I think I have to lean towards maceo's perspective. For those of you have gone through internship, I'm sure you yourself or someone you know has gone and written RRR or CTA B/L while rounding on a patient post-call without doing the pertinent exam. Does that make you a bad doctor? No. It happens to almost everyone and the goal I would hope is to do your best to avoid it and learn from cases like this one. I heard of an instance where a resident wrote RRR and the patient up being in afib. Bad, yes, but it does happen.

Of course it does, we all realize that.

I would be much more concerned if the resident faked a result, was called on it, and lied and said they did it. Admit the mistake, and learn from it. I find that lying afterwards to be far more serious a mistake and personality flaw than being exhausted after x straight hours on call and taking a shortcut that many have and will continue to do.

So you have no problem with the fact that the OP DIDN'T learn from his mistake? He admits he did it two years ago, lied about it, was caught and put on probation. Then he does it AGAIN.

The issue is not the shortcut but his medical judgement to do something that he knows not only potentially endangers the patient but his career. Where do you draw the line at "no more chances"?

 

[dragonfly99]

I think the program already wanted to get rid of this resident.
What he did was wrong, but I've seen a lot of house staff do wrong things, and some get held accountable and others don't. If he was the "favorite son" of the PD, you can be he wouldn't have gotten kicked out. He probably either had made other mistakes/causes problems and/or had a personality that the PD and chief resident(s) didn't like.

What he did was pretty bad, though...he needs to realize he made a seriously bad mistake. I'd try to enter another specialty not involving OB...and try to gather some LOR's from faculty who want to see him continue in his career.

 

[Law2Doc]

You are a medical student. I dont know what stage you are at but sounds pretty early. YOu cant judge someone especiall in medicine unless youve been there. You dont know what being an intern is. you have no idea. You dont know the time pressures and the sheer volume that the intern has to pick up. They are gonna make mistakes and certainly this one is a minor one that does not merit firing. He/ she is there to learn. I dont give a rats arse about your legal backround. I really dont. Lawyers are what is wrong with the system. I would go under oath to say I wouldnt terminate this person.

And if you were the PD, then you would subject YOURSELF up to enormous liability for negligent supervision, by letting someone you know falsified medical records simply go about his business. If it happens again and god forbid someone does get hurt, how do you think it sounds to a jury when it comes out that this person had the same issues before and YOU knew about it, and did nothing. It's indefensible. So yes, anyone can judge someone regarding this kind of conduct. Heck, a judge is going to judge someone on this kind of conduct if something goes bad with the kid. It is NOT a minor slip up. It is a big big deal to falsify a medical record and claim to have done a procedure you didn't.

I don't know where you are an attending, but having no clue as to how liability works is VERY dangerous for your career. So yes you NEED to listen to a lawyer's views on this kind of thing, because it's the legal ramifications that are where you get burned here. This is a legal issue, not a resident issue. So guess what -- a lawyer's view is important here, more important than an attendings, I suggest. Doesn't matter whether I understand firsthand what it's like being a resident, it's you who doesn't understand what happens when you get hauled into court on this kind of issue (while a lawyer most definitely does).

Time pressures, volume, etc are what everyone has to deal with (not just in medicine, BTW), but it never justifies cutting corners. It just doesn't. An overworked associate at a law firm has the same incentive to cut corners, puff up his billings, say he looked at things he didn't. That kind of dangerous incentive exists in any long houred high pressure job, and residents don't have a monopoly on this. But when you start falsifying records, you have screwed up, and yes that kind of screw up is a fireable offense. Not just in medicine, but in any professional field. You don't want to go there. And as an "attending" you really ought to know better. Trying to demean other posters by "assuming" where they are in their careers doesn't make it any more comprehensible that you have no problem with this kind of activity, which is on its face negligent, often illegal (since the hospital bills for the things you say you do - so it's technically insurance fraud), and puts residency programs in jeopardy.

 

[Winged Scapula]

I think the program already wanted to get rid of this resident.
What he did was wrong, but I've seen a lot of house staff do wrong things, and some get held accountable and others don't. If he was the "favorite son" of the PD, you can be he wouldn't have gotten kicked out. He probably either had made other mistakes/causes problems and/or had a personality that the PD and chief resident(s) didn't like.

What he did was pretty bad, though...he needs to realize he made a seriously bad mistake. I'd try to enter another specialty not involving OB...and try to gather some LOR's from faculty who want to see him continue in his career.

Agreed.

We all make mistakes. If we didn't, there'd be no need for residency. As we say in surgery, "there's a reason why its a 5/7 year program."

But making mistakes AND not being well liked, is a recipe for termination. I also suspect that this resident was merely tolerated and when the mistakes became too much, the program had more than enough ammunition to terminate with just cause.

As I've often said, I'm fairly sure that because my PD liked me, he was more lenient on me when I made mistakes than some of my colleagues.

 

[NotAProgDirector]

How did he put anyone at risk? The fhr were normal. the patient did well where did he put someone at risk?

I find this statement terrifying. This is one of the things seriously wrong with medicine today. Something doesn't need to "go wrong" for care to be bad. I doubt this was the only time the OP took a shortcut -- likely it happened multiple times beforehand but was never caught. Somewhere, behavior like this will hurt someone. It must be stopped, with a zero tolerance policy.

I agree with the OP's PD's decision. I would have done the same thing, with perhaps one addition. The first time it is caught, I put the resident on probation and state very clearly: "if this happens again, at any time, for any reason, you are fired."

There are several "unforgivable sins" in medical training:

1. Lying - to your PD, to other docs, to patients, etc.
2. Falsifying medical records -- which is similar to #1, but deserves it's own spot
3. Boundary violations -- sleeping with patients, abusing patient trust
4. Stealing meds / narcotics -- note that having a drug problem is NOT on this list, but stealing narcotics from patients or "the system" is.
5. Looking in colleagues medical records (if not involved in their care)

All of these lead to probation, termination if repeated.

I'm sure you yourself or someone you know has gone and written RRR or CTA B/L while rounding on a patient post-call without doing the pertinent exam. Does that make you a bad doctor? No.

Actually, yes it does. If you didn't examine the patient post call because you were too busy doing something else, just tell me that.

This type of behavior is completely unacceptable at any level. It needs to be stopped at the student/residennt level, or it will continue.

I do realise what i did put someone's unborn life at risk, accept my termination, will take all the scum hurled at me, but all I ask is for a process of remediation and if I can survive that, let me continue. If I fail, I quit. Surely there has to be some path to tread upon...

I am very heartened by the fact that you seem to accept this. The price you will need to pay will be quite steep. If your own program will not take you back, you will likely need to start over as a PGY-2 as the ABFP requires that the last 2 years of training be at the same institution.

As others have mentioned, I worry that your program may have been worried about your performance for some time, and then used this event, appropriately, to terminate you. If so, you will find getting a new program difficult. If not, then I expect your PD might try to help you get a new program. Expect to be "on probation" from day #1 at your new program -- i.e. they will watch you very closely, and if anything like this happens again you would be terminated immediately.

 

[michaelrack]

I heard of an instance where a resident wrote RRR and the patient up being in afib. Bad, yes, but it does happen.

.

There is a difference between falsifying the medical record (like the OP did) and being sloppy.

If one listens to the heart for just a second or 2, its possible to mistake afib for a regular rhythm. Other shortcuts include listening at a single point at the chest and documenting normal heart, lungs, abdomen (This is something ascribed to some surgeons, as a board certified internist I do NOT do this); briefly glancing at a patient and documenting normal cranial nerves. Most doctors have been sloppy and taken short cuts at some point in their careers. However, falsifying a medical record is intolerable.

 

[Old_Mil]

I saw this last year:

Senior FM attending had been running behind all day. Last patient of the day came in as a walk in appt with chest pain. The nurse told him 'i think this guy is in bad shape, he's sweating and not moving really well.'

The doc goes into the room, says 'I'm running late today and don't have time...it's probably GERD. Take antacids.'

No physical exam. Guy goes home. Presents at the ED 30 hours later, EKG at the ED is grossly abnormal, he dies Friday evening in the cath lab.

The H&P done by the attending was grossly false, listing all the usual MI sx as pertinent negtatives though he didn't check for a single one.

He's still working there by the way.

The moral of the story is that the rightness or wrongness of your actions in medicine are judged on your seniority, not against a gold standard that everyone must live by. For all the discussion regarding professionalism, medicine is about as far from a professional field as you can get. It has the atomosphere and the personalities of an animal house initiation, patients be damned.

Understand what you've gotten yourself involved in, and then you'll understand the way to get yourself out.

 

[dragonfly99]

old mil,
that sounds like an extreme example and something I've NEVER seen. And I'm at the fellow level, by the way. Sloppiness, I have seen. Being in a hurry, I have seen. Honestly infrequently, though...most all the docs I've worked with have been very concerned with providing good patient care and good clinical outcomes and really care about their patients. Some of these same docs could be harsh even to the point of being heartless to trainees, but not to their patients. Blatant fraud and negligence, to the point of malpractice, I have never seen. That physician could certainly be sued, and I'm surprised he wasn't.

But I will agree with you to an extent about the double standards. Attendings, in general, can get away with much more than trainees. We are being watched, and they are considered "fully fledged" docs so unless they do something obviously and grossly improper, they may get away with it.

 

[silas2642]

I saw this last year:

Senior FM attending had been running behind all day. Last patient of the day came in as a walk in appt with chest pain. The nurse told him 'i think this guy is in bad shape, he's sweating and not moving really well.'

The doc goes into the room, says 'I'm running late today and don't have time...it's probably GERD. Take antacids.'

No physical exam. Guy goes home. Presents at the ED 30 hours later, EKG at the ED is grossly abnormal, he dies Friday evening in the cath lab.

The H&P done by the attending was grossly false, listing all the usual MI sx as pertinent negtatives though he didn't check for a single one.

He's still working there by the way.

The moral of the story is that the rightness or wrongness of your actions in medicine are judged on your seniority, not against a gold standard that everyone must live by. For all the discussion regarding professionalism, medicine is about as far from a professional field as you can get. It has the atomosphere and the personalities of an animal house initiation, patients be damned.

Understand what you've gotten yourself involved in, and then you'll understand the way to get yourself out.

A similar incident happened in a hospital that i used to work at-- a physician was behind or something and she dictated an H&P on an admission she'd never even seen and the patient died. She lost her license over this incident after being declared by the state board to be an "imminent threat to patients." So there are consequences to sloppy work-- it's not always about seniority. I think that there is still right and wrong because at the end of the day, you're the one who has to look at yourself in the mirror. That physician may not have lost his license, but maybe someday he will, and he's the one who has to face the family and potentially a lawsuit.

 

[Substance]

I think the program already wanted to get rid of this resident.
What he did was wrong, but I've seen a lot of house staff do wrong things, and some get held accountable and others don't. If he was the "favorite son" of the PD, you can be he wouldn't have gotten kicked out. He probably either had made other mistakes/causes problems and/or had a personality that the PD and chief resident(s) didn't like.

What he did was pretty bad, though...he needs to realize he made a seriously bad mistake. I'd try to enter another specialty not involving OB...and try to gather some LOR's from faculty who want to see him continue in his career.

I agree with this.

There's always someone who is the butt of the program, and that someone seems to be the OP. My guess is that you're some sort of passive yet eagerly submissive fella with a really thick accent. No matter...your program is giving you the boot because they want you gone, not because they're following any protocols.

Whether I would terminate you or not is not a matter I can comment on, since I only know your side of the story.

Also, be weary of your reference letters. If they're coming from people in your program, they might not be as good as you think...


I think that the judgment of your actions is not just based on seniority, but on how many other doctors are nearby. It's not illegal if nobody sees you do it. The FP described by Old Mil seemed to run his own show, and had no supervision. The internist described by silas was accompanied by many other physicians in a busy ER.

 

[silas2642]

I agree with this.

There's always someone who is the butt of the program, and that someone seems to be the OP. My guess is that you're some sort of passive yet eagerly submissive fella with a really thick accent. No matter...your program is giving you the boot because they want you gone, not because they're following any protocols.

Whether I would terminate you or not is not a matter I can comment on, since I only know your side of the story.

Also, be weary of your reference letters. If they're coming from people in your program, they might not be as good as you think...


I think that the judgment of your actions is not just based on seniority, but on how many other doctors are nearby. It's not illegal if nobody sees you do it. The FP described by Old Mil seemed to run his own show, and had no supervision. The internist described by silas was accompanied by many other physicians in a busy ER.

I know I'm still very wet behind the ears and see things probably more in black and white than experienced clinicians, but when it comes to "breaking the law" and meeting patient standards-- you either do it or you don't. It doesn't matter whether or not another colleague saw you do it or not. If you did something illegal or unethical, it doesn't really matter if you got caught or not; if you get caught then you're up a creek without a paddle; the point is you did something wrong and someone either got hurt or could have gotten hurt.

The OP may have been the "butt" of the program, but the point is he wasn't following the rules that physicians are supposed to follow and his termination was justified, as confirmed by several attending physicians, including a program director. You can't falsify a patients medical record, and you can't lie to your attending about patient care-- twice and get away with it. His actions were endangering patients, and he needed to be dismissed until, at the very least, he can get his act together to return to medicine. No one made him make the poor choices that he did-- he is not the victim here.

 

[dragonfly99]

silas
yes, you are wet behind the ears.
Substance was incorrect to say that "it's not illegal if nobody sees you do it". However, there are many cases where attendings write down parts of the exam and ROS that they did not do. It's not just residents and med students who do this. Attendings often don't really examine the patient well, especially if they trust the resident who did the initial H and P. Yet, for billing purposes they have to write that they did the exam...or at least "confirmed the H and P of the resident" ...when a lot of the time they did a very cursory listening of the heart and lungs, and that's about it. A lot of the extensive H and P and exam stuff that is required for medical billing can potentially lead to documentation of parts of the physical exam that weren't really done (like a complete neuro exam, etc.), mostly due to time pressure. Still, it's really important to not write down parts of the exam you haven't done...if you didn't do a neuro exam, just leave it blank or write "exam deferred". You have to learn what parts of the exam are necessary for certain chief complaints...if you are a student or intern, have to assume the answer is "everything". It would be nice in the real world if we had time to do a complete exam on every patient, but the reality is different...but it's still important to know which parts are important (i.e. FHR in a laboring woman) medically and definitely do those.

However, not recording a FHR and then making one up and putting it in the medical record is another ball of wax.

 

[koh]

As the foo fighters said.."Its times like these you learn to live again.."

I am also working on my second chance at residency and medicine. My situation is a little different from yours. The only thing I can say to you is continue to follow your dreams. I know you probably feel like crap. There is probably alot of shame and anger at yourself too. Dont let anyone tell you that you cannot bounce back. Find a new path. Your path is still out there but youre gonna have to overcome your situation, find a new way and pursue it. For me that process took a long time. I can tell you from the outset alot of people told me I was done and there were alot (many more acutally)of people that told me what I im telling you..continue walking. It took me a while (almost a year) to take some self inventory, figure out what changes I needed to make with me and then figure out where I go from here.

Everybody makes mistakes. Anyone who tells you they are perfect and has lived a perfect life is either lying to themself or they havent lived long enough. There are people out there who realize this and will give you a second chance but they are not going to find you while your wallowing in your guilt and shame, you will have to do your own growing from this and then step out and find them. I started the match process this year thinking that no one would give me a second chance. Then the miracle happened..i got an interview. By the time it was all said and done I had way more than I could attend. My situation took a job from me but I gained so much personal growth that I almost shutter to think about where I would be if I had not had to endure it. There is hope.

Great talk and encouragement. I wish I can have your personal e-mail to caht with you about my situation and get some advise from you.
Thanks