terminated weeks after promotion, no review, no probation, "due process" behind closed doors?!?!

Discussion in 'General Residency Issues' started by resident_spouse, 09.22.14.

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  1. resident_spouse

    resident_spouse

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    RESIDENT was drastically fired from her family medicine residency at PROGRAM this July 2014. She immediately appealed to the PROGRAM’s board of directors, which after two months of mostly silence, simply denied her appeal without offering any other communication. Her questions, requests for information, objections, and concerns about violations of ACGME requirements were flat out ignored.


    The rest of this letter, describes events and circumstances surrounding RESIDENT’s termination. There is ample evidence that her termination was unjustified and in stark violation of multiple PROGRAM and ACGME policies. Worse than the very real and existential threat to RESIDENT’s livelihood, is the way RESIDENT has been treated, the way she was being pressured to resign before being terminated, and the extent to which her concerns, objections, and questions with regard to her termination were ignored even when she appealed to the PROGRAM’s board of directors.


    Leading up to her termination, RESIDENT --feeling desperately overworked and behind on her medical documentation-- requested any options that would lower her workload; even offered to extend her residency over an additional year. In response, she was told to take a week to catch her breath and complete outstanding documentation. It was not until halfway through this week that she was informed (in writing by PD) that failure to complete ANY outstanding responsibilities would result in immediate termination for academic reasons.


    The email dialogs between RESIDENT and her Program Director(PD) over the past year, make it more than evident that PD was growing increasingly frustrated with RESIDENT voicing her concerns about duty hours violations and patient safety issues arising from hasty documentation practices being forced on residents.


    Several emails specifically, further suggest, that RESIDENT has been assigned higher workload (e.g. being assigned higher significantly patient load) directly in response to raising concerns, and has faced disciplinary action (eg. having certain batching privileges revoked) without being given any justifiable reason whatsoever (despite requesting to know the reason).


    I believe the following items to be facts, but will immediately inform anyone in receipt of this email if presented with any evidence to suggest otherwise:

    • The ACGME requires that when reviewing evaluation and reasons for nonrenewal of appointments, the resident must be allowed a fair hearing and due process.

    • The ACGME requires the sponsoring institution to give a resident at least a four-month written notice when his or her performance is unfavorable for promotion or the program is considering termination.

    • RESIDENT has never denied that she was behind and unable to catch up on documentation, but PROGRAMS’s EMR software also shows that --during the past year-- RESIDENT, as an R2 was responsible for more documents and patients than any of the other residents in the entire program, including senior 3rd year residents.

    • During her entire time at PROGRAM, RESIDENT was never placed on review or probation. She was promoted from R2 to R3 less than month before being terminated without any notice of unsatisfactory performance.

    • Although the week to work on outstanding documentation was originally presented to her as the result of her advisor speaking to PD, (RESIDENT had appealed to her advisor about options to reduce her workload in an email and subsequent meeting), RESIDENTS’s advisor did not even know that she had been terminated until RESIDENT emailed her a week after the fact!

    • RESIDENT was not informed about where or when the board meeting to address her appeal was held. She was not allowed to attend the meeting. She also was not informed who was present / making this decision.

    • RESIDENT has talked to at least one other resident who resigned from PROGRAM in the past for personal reasons and learned that this resident was also pressured to resign.

    I personally, find it incredibly hard to imagine genuinely malevolent intentions by PD or other PROGRAM administrators, but at this point am at a complete loss as to what other conclusion to be arriving at. Indeed, PD tried strongly to pressure RESIDENT into resigning, offering letters of recommendation and help finding another residency. If she would not resign voluntarily, she would be fired for academic reasons, was certainly not to expect any letters of recommendation, and should expect never to be able to practice family medicine again! I simply cannot fathom any set circumstances under which this dichotomy can be considered, or appears even remotely ethical or just.


    What would you do? The ACGME doesn’t handle individual disputes, legal action would take years, meanwhile finding another residency is proving very challenging. Even if RESIDENT finds a new program, either her or her spouse ends up a single parent with 2 toddlers unless spouse was to throw career (and currently only means of support) out the window.


    [edited: I removed one of the items in the list in favor of anonymity.]
     
    Last edited: 09.22.14
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  3. colbgw02

    colbgw02 Delightfully Tacky 10+ Year Member

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    I am certain that this represents an unbiased, unabridged account of the events.
     
  4. resident_spouse

    resident_spouse

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    Most certainly not. I have no illusions about being able to remain objective. That said. This is all true to the best of my knowledge. I am desperate to make sense of the situation, have no good reason not to trust my wife, and the program won't answer any of my questions.

    At a loss as what to do next :(
     
  5. resident_spouse

    resident_spouse

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    Except for the last paragraph, the text I posted is the majority of a letter I am considering sending to the other residents and faculty at the program.
     
  6. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    Don't do this
     
  7. colbgw02

    colbgw02 Delightfully Tacky 10+ Year Member

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    Apart from emotional release, I don't see anything to be gained by you, the physician's spouse, sending a letter to anyone.

    If you truly believe your wife has been wronged, and there is enough at stake, then retain an attorney. You probably want to quit posting about it, too, if that's the route you choose.
     
  8. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    To clarify...

    I know that you and your wife are hurting. I know that you are angry and feel slighted.

    I know nothing about your wife's program, nor whether this firing was fair, unfair, egregious, or illegal.

    What I do know is this. Both of you, right now, need to be focused on one thing - your future.

    Sending a letter like this does absolutely nothing to help that future, and in fact would potentially significantly harm your wife's future regardless of what options you choose going forward for her career.

    The residents and faculty will not be moved by this letter. It won't change anyone's opinion. It won't help anyone.
     
  9. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    Agree with the last part. This is just a bad letter, plain and simple. It doesn't really paint your spouse in a positive light, you are absolutely the wrong person to be fighting this battle, and the reader definitely comes away from reading this letter thinking that you apparently think the program ought to lose on technicalities (things like not enough notice, not informing her who is part of certain committees) rather than that your spouse is blameless. Sometimes you can "win" on technicalities but you don't ever rally the troops talking about them. You could consider a lawyer, but the letter won't help.
     
  10. resident_spouse

    resident_spouse

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    First of all thank you for taking the time to respond. If my inline answers sound too pessimistic I apologise, it's hard to find positive thoughts at the moment. I do appreciate and am taking to heart your words and advice.

    >> Apart from emotional release, I don't see anything to be gained by you, the physician's spouse, sending a letter to anyone.

    Although I am obviously biased, doesn't the support of second person lend at least a little bit of credibility...at least it means she's not crazy to the point that even her spouse ignores her complaints?!


    >> If you truly believe your wife has been wronged, and there is enough at stake, then retain an attorney.
    I understand. We have talked to multiple attorneys. Most of the larger firms around here have some sort of conflict of interest, a few have dismissed our concerns with "this is a work at will state". The ones that actually listened and are looking into the case, have no experience with residency / graduate medical education. I'm sure their capable of researching the contexts and unless I'm missing something / my wife is hiding something (again I have no reason whatsoever to believe that she does, other than the whole thing sounding outragious) and can win the case if its winnable....but we are talking more than a few years down the road


    >> What I do know is this. Both of you, right now, need to be focused on one thing - your future.
    I've sacrificed multiple very good career opportunities to support and be able to follow my wife geographically. I didn't mind at all, instead started my own business, which is finally starting to generate some halfway decent income (and currently the only income our family of 4, with a 5 and 3 year old at home, has available). So even if my wife finds another residency, one of us ends up a single parent. Parenting as a team is hard enough...I literally cant imagine the stress of being a single parent while either starting over at a different resident (with the added stigma of having been fired from residency before) or trying to run your own business. If I left my business, we would have to file for bankruptcy within months...and , oh right, that still wouldnt make a dent in the $200,000 student loans well have to pay...

    I just can't come to terms with the fact that someone can destory everything we have worked for because of a personality conflict / they don't like the fact that my wife won't lets someone be intimidate her into submission.

    Sorry...im starting to rant / vent...I'm having a hard time even imagining options for where we can go from here.

    I suppose legal action might eventually hold someone accountable...but to be honest I'm finding little comfort in the idea of being compensated years down the line when it means financial disaster during the most formative years of my children.... :(


    >> Sending a letter like this does absolutely nothing to help that future,
    >> and in fact would potentially significantly harm your wife's future regardless
    >> of what options you choose going forward for her career.

    how? i think i get your point...im just not able to come up with a specific scenario right now.

    >> The residents and faculty will not be moved by this letter. It won't change anyone's opinion. It won't help anyone.
    The two residents I have talked to are completly supportive of my wife, but afraid to speak up (understandable, especially if they don't think they are in a position to make a difference for my wife). But I refuse to believe that there is not at least one person in the local medical community that upon being confronted with this situation and evidence will see it as their moral obligation too do something (either if they are in a position to do something or by advocating to those who are...). At least ask questions / look into the details. Am I being gullible?
     
  11. resident_spouse

    resident_spouse

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    I guess I wasn't considering these things technicalities...

    What would a non technical reason for the program to loose look like?


    >> things like not enough notice, not informing her who is part of certain committees
    Other than these procedures (and review/probation, which were just skipped entirely), what procedures are there to protect potentially innocent residents in a situation like this?
     
  12. aProgDirector

    aProgDirector Pastafarians Unite! SDN Advisor SDN Moderator 10+ Year Member

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    I'm going to agree with the other advice here. Getting involved as her spouse (other than supporting her) and specifically sending an email like this is certain to make things worse. You only know 1/2 the story, if that. Please note that this (very) long post does not mean that I agree with the result that your wife was fired.

    More specifically, regarding your email:

    Any concerns about ACGME violations are important, but have nothing to do with her performance.

    Let's stop right here. Residents do not get "time off to catch up on documentation". Documentation is required in a timely fashion in all venues. As a PD, I take people who are "desperately behind on their paperwork" and put them on a remediation plan that 1) removes them from clinical duty; 2) makes them pay back anyone affected (and/or make up the time); and 3) make it 100% clear that if it happens again, they will be terminated. It's unlikely that her program simply said "take some time, don't worry about it.".

    This really depends on the situation. If everyone else can do the documentation in a reasonable timeframe and your wife can't, that's a problem. If the workload is truly too high for any reasonable person to do the documentation, then that's a real problem. We can't really tell from your description.

    This is too vague to comment upon. I totally agree it is unacceptable for a program to increase a resident's work load due to complaints. On the other hand, if you have written documentation of such this is a gold mine for a lawsuit, perhaps under whistleblower statutes. (Not a lawyer, no idea if this would really work...)

    This is correct. The ACGME does not state what that due process is, nor what has to happen at a fair hearing. A program must have a written policy of their fair hearing / due process, and then must follow it.
    I think this is true. I hunted through the PR's and having trouble finding it. In any case, it is worded as "120 days when feasible" or something like that. Mostly this rule is in regards to not renewing a contract, not on being fired. So it is completely possible for her program to terminate her without 120 days notice.

    If your wife showed you EMR data, that's potentially a HIPPA violation on her part. But, she can prove that she was made to work harder than others in order to make her fail, that's a huge plus for her (in any legal proceeding)

    There is no requirement to place anyone on review or probation prior to being fired. And, as mentioned above, she was removed from clinical work to get caught up. Many would consider this a form of "review" or "probation".

    There is no requirement to notify any faculty about the termination. Perhaps this was poor form, but it's not illegal. In fact, disclosing details of the resident's termination to others outside the program might be considered illegal.

    This is an important issue. In general, residents are allowed to come to their fair hearings. However, if this institution's policy is that residents can't come to their fair hearing, then that's the rule. Seems "unfair" to me, but I could imagine that a fair hearing could be set up where neither the PD nor resident get to attend, both submit documents in writing, and the committee reviews. Not the way I would set it up, but this is not a trial.

    This complicates matters further. I assume IPHP stands for Impaired Physician's Health Program, or something similar. It's not clear from your letter why this would be necessary, but perhaps because of the stress/overwhelmed issue. Personally, I have a huge problem with these types of requirements. Whether she decides to see a therapist is her business, not anyone else's. All I care about (as her boss) is her performance at work. If seeing a therapist might help, I say "Hey, seeing a therapist might help you" but it's none of my business if she goes or not. What is my business is whether her performance improves. If I'm very concerned about her health / drugs / psych issues, then I order a "fit for duty" exam done in Occ Med that only tells me two things -- is she fit for duty (with or without accomodations) or not. Everything else remains private.

    In general, most residents that get some sort of ongoing care work it into their schedule -- choosing the last appointment of the day, or 1st in the AM, so that it doesn't affect their schedule. If this wasn't possible, she can request sick time off for this (her program should have some sort of policy on that).

    This has been a discussion on other threads. I completely agree with you. This whole "resign instead of being fired" shenanigans is crazy. In reality, it's a way for a program to avoid the whole due process / fair hearing thing, so they offer a resident a faustian bargain -- resign and we'll write a nice letter for you that covers up the real reason we wanted to fire you. I agree this is crazy, and this type of behavior is what allows people with real problems to move somewhere new and create havoc again.

    What I would NOT do is send this as a letter. You could easily find yourself the target of a harrassment or libel lawsuit. There is no easy answer here. Perhaps your wife was completely wronged, fired on trumped up charges. Perhaps her performance was really sub par and this was the end of the line. I don't know, and neither do you.

    Your options:
    1. You could see if you have a lawsuit for illegal termination. Usually the results of these lawsuits don't ride on whether your wife "deserved it" or not, but simply on the question of whether the program followed it's own rules. Was the fair hearing held per the rules the program has defined? Were all the steps followed? If not, courts may force back pay and (perhaps) reinstate her -- although usually in that case a program will find a way to negotiate that you leave in good graces.

    2. You could find a new program. I agree it won't be easy. FM requires (I think) the last 2 years be completed in the same program, so she would likely need to start as an R2 again. There are funding problems. Much depends on how competitive she was prior to matching.

    3. If not an IMG, she can apply for a full license in many states, and try and work.

    4. If her relationship with her PD is not completely toast, she could ask for a mediated meeting. Each of you have someone there to discuss the situation. This would allow someone less emotionally involved than her hear what the issues really are. I am not certain that you qualify as being less "emotionally involved".
     
  13. colbgw02

    colbgw02 Delightfully Tacky 10+ Year Member

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    No, not if that second person is the spouse. I feel like this should be self-evident.

    What does it tell you that these admittedly powerless residents won't speak up? Do you think your letter will spur them into action? No, it won't. The only person who might be able to help you is a faculty member who has the ear of the PD. If there is such a person, see if your spouse can sit down with him or her. However, based upon what you've written, I doubt such a person exists.
     
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  14. Dral

    Dral 7+ Year Member

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    Does her hospital system have an ombudsman? For some reason, I'm guessing no. Mine does, and it's who residents can go to if they have problems like this. I don't think many residents in my program go to ours...I haven't heard of anyone in any of our programs recently terminated...but I do know such a person exists.
     
  15. resident_spouse

    resident_spouse

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    Thank you everyone for your input. I'm smart enough to take a hint when more than 2 people advise the same thing, so no letter or further posts.

    FYI:
    She was certainly not the only one behind on documentation. For most of the past year the residents I talked to said they were far more behind than her during most of the year.

    From what I gather multiple residents have been suspended from clinic on numerous occasions for being behind on documentation (and my wife was too earlier this year)

    She did refuse to "just do them faster", felt like the implication was to make the emr system / billing department happy rather than care about the patient.

    She never showed me any patient data just the result of a query for how many patients and documents everyone was responsible or for. (Worth noting she was responsible for more than any other resident). She just talked to a friend at a different residency (also just went from R2 to R3). Her friend had ~500 clinic patient encounters. My wife had over 1100.

    I understand there is another side to every story...it's just very frustrating when they won't say much at all. I did send some of the above concerns to PD asking to help me understand / tell me what I was missing....only to get "some of your questions are for your wife to answer, others for herself to contemplate" as a response.
     
  16. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    The bottom line is...this is not a battle you can fight for your wife
     
  17. Dral

    Dral 7+ Year Member

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    There are a lot of comparisons to others flying around. It seems it should be fewer comparisons, and more focusing on her things, whatever those may be.

    Nobody gets fired for seeing tons of patients as long as it's not at the expense of something else. Per usual with these situations, there is something missing here.

    My experience is limited, but residents who are put in this situation don't seem to have the best self-awareness to help them determine why they are in their situation.

    As an example, I can document that my patient's cousin's pet goldfish just died and claim it's important for patient care. Is it really though? Being a good and efficient doctor is about knowing what's important...not being absolutely comprehensive to a fault.

    I understand residency is unique in that others may read your documentation if they pick up your patients, but there is a line.

    Granted I'm in a field that often sees fairly simple problems, but here is a typical history of one of my notes:

    28 y/o M with itchy Seb Derm on scalp for 5 months responding to Nizoral TIW.

    I hit my 4 descriptors and hit the high points. Notice that I left out the part about how the pts wife just developed a rash on her hand which I heard all about. I know it's not relevant to my present case.

    I'm not being accusatory, just trying to start a hopefully productive discussion.
     
    Last edited: 09.22.14
  18. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    The comparisons to others, particularly residents at other programs, are as you note irrelevant.

    Especially the attempts to quantify patient care via the EMR
     
  19. Dral

    Dral 7+ Year Member

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    Exactly. I would argue that EMR or any documentation is to EFFICIENTLY transmit information, cover medico-legal aspects, and document proof of billing criteria. It is not proof of good pt care imo...part of, but not proof of.
     
  20. BlondeDocteur

    BlondeDocteur 7+ Year Member

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    I think it might be hard for you as an outsider to medicine to appreciate how blazingly unusual, and unacceptable, it is to be months behind on clinical documentation. It's even more of a scarlet red flag to be given an entire week off of work just to write notes. Without notes you have no record of what the patient said, what their exam was like, what your relevant workup was, what your thought processes were, and what you ended up actually doing for the patient. There is zero chance you will successfully be able to reconstruct the encounter weeks to months later. No one else taking care of the patient will know what you did. Your department can't bill for your services. Should their be a question of malpractice or liability there will be no record of your treatment. Most places have all these internal alarm bells that go off if certain kinds of notes aren't completed in 3, occasionally 7, days. For her to be buried under a mountain of old notes is really, really unusual and unacceptable.
     
  21. IM2GI

    IM2GI

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    This is the truth. You really cannot understand the impact of your wife's actions if you are not in healthcare.

    Under this guise of "not compromising" on her notes, she likely was writing terrible and inaccurate notes, because you just cannot remember what you did in detail that far out. It also implies to me that she was not following up on her plans. The short note that I write the day I see the patient will be a lot better than the note I try to sit down and write a month later.

    The reality is your wife has a crippling issue with documentation. We all feel it, but at the end of the day you have to get your notes done or you are not doing anyone any good. Once you get behind on notes, in an apparently large volume practice, it becomes very difficult to catch up.

    There seems to be plenty of blame to go around, but your wife is not doing herself any favors by pretending she is the righteous one in this situation.
     
  22. AStark

    AStark 2+ Year Member

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    I have to agree with everyone else. About the worst I'd get in my documentation is finishing up daily ICU progress notes later at night on particularly busy days. I can't imagine not completing a progress or clinic note on the same day. I don't even like saving my dictations until after clinic because I tend to forget details. That's not to say I appreciate all the details of this particular situation, but timely documentation is a straightforward and basic requirement.
     
    Last edited: 09.23.14
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  23. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    Documentation is the bane of my existence. OCD people - myself being one of them - feel compelled to detail every little thing, usually relevant, but not necessarily something that will shape the course of care. The billing system (must have 12 system ROS, etc.) doesn't help things, but in my short experience the best attendings write brief notes that give us a glimpse, an impression, of what the patient was like when we saw him last. The PE often has only 4-6 systems listed (e.g. for strong suspicion of aspiration PNA note the vitals, the mental status, global neurologic status, speech and swallowing, OP appearance and dentition, and heart and lung sounds with just a few positive and negative details - you don't need all this extra NC/AT/PERRLA/EOMI/no joint swelling/DTRS 2+/acanthosis nigricans/livedo reticularis/umbilical hernia/blablabla BS). The history is complete but not exhaustive. The plan states the problems and what will be done, with very little extra fluff. Certainly none of the roundabout flowery consideration of everything and anything that could be going on. That thought process should be going on inside the clinician's mind, and does not need to be addressed and systematically detailed in written form.

    In short, the exhaustive 8 page H&P we're taught as medical students to write on our IM and pediatrics rotations does us no service and entrains us to think and do things in ways that are counterproductive in the real practice of medicine. On the other hand, the surgical services are often way too terse to the point of it being inscrutable to outsiders. The real art of it is how to eliminate in our own minds most all the less likely diagnoses, and then just say what we're thinking, how we'll address it, and how we'll cover our bases for anything super serious but unlikely. I just wish they let us do this in medical school so we wouldn't have to unlearn all the bad habits they pushed on us.
     
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  24. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    Just to pile on and echo what others have said,
    1. it's not helpful to focus on what others are being required to do and particularly others at different residencies. This isn't about anyone else, it's about whether your spouse is getting the job done. Some of the other residents in your program could also be on thin ice or greatly exaggerate how tardy they are with documentation to make your wife feel better. As for other residencies, some places have reputations of being cushy while others are sweatshops. Some are looked at as more adventageous because you do more cases/procedure/see cooler things. With that better education often comes more paperwork, call, whatever. When I was n intern, we routinely hit the 80 hour per week ceiling. I know people at cushy transitional years who rarely hit 60. I'm quite sure I did more paperwork. More of everything. It's apples and oranges.

    2. Documentation is part of the job. It not just an extra chore on top of the job. Caring for patients well but not doing paperwork timely is kind if like being a waiter who brings all your food quickly but then takes hours getting your check. It translates to not being able to do the job.

    3. When I said "technicality" I was describing all the procedural stuff you said didn't happen in the course of the firing, which you are apparently focused on. Focusing on a non-technicality would be saying your spouse didn't do (or not do) that which she's being fired for. Sounds like In terms of documentation, there was a legit reason for the program to take issue. You really just don't like how they did it. Yes, Sometimes that's a winning argument in court, but it's never ever one that gets outside people's support. It's like saying the accused should go free because the prosecutor didn't follow their protocol -- it's part of our jurisprudence but nobody is usually that happy that justice is getting done.

    4. As mentioned, you as spouse aren't an impartial individual. You aren't a "second person" who can lend credibility. You are an extension of the first person. Im most troubled by the hint that you may have asked other residents to come forward in your spouses defense. That is very inappropriate and would basically be trying to throw others under the bus because your wife got run over. Your only ally here should be an attending/mentor, if your wife has one. Someone who can talk to the PD as a colleague, not an underling.

    5. "options to reduce workload" often don't exist in residency. It's an intense training meant to occur within a finite period of time. And the funding is allotted for that finite number of years. To some extent the stresses of residency prepare and teach you toward the stresses of practice. while a program can do whatever they like, there is no expectation or mechanism to let them extend residency for someone who is just raking longer to do the documentation, if that's what you are suggesting. You can't expect a sweatshop residency to adjust to a more cushy approach to give someone time to catch up. If they did that for your spouse they'd have to for everyone. And attendings would have to pick up the slack. Most places won't want to go down this road.
     
    Last edited: 09.23.14
  25. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING 5+ Year Member

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    Yes, I mean this is what everyone keeps talking about here and this is what's going to kill her. It's incredibly unusual for people to fall more than a day behind on documentation. Incredibly. Unusual. Even the slowest residents I've seen (although granted I am at a large academic institution) get their notes done that day. You don't get weeks behind on documentation. It just doesn't happen. It's bad patient care, it's bad for billing reasons, it's bad because nobody else can figure out what the heck you did with the patient. Especially in the outpatient FM world...we all know how resident clinics work. What if that same patient came back to clinic a week later, saw a different resident and there was no documentation of what happened during her encounter? Unacceptable. Especially as a R 2/3. I mean, do you think it would be acceptable for a program to send her out into private practice with a history of not being able to complete timely notes (arguably one of the more important things in outpatient medicine)? A resident getting a week to just work on notes is very much unheard of and signifies a significant problem.

    From the story, it seems that 1) she didn't want to write shorter notes because she believed it would "compromise patient care" (without having any data to support said assertion I assume) and 2) she didnt want to violate duty hours. Well, other people have already talked about number 1, but at the end of the day everyone either learns to adapt to writing more efficient notes or drown under paperwork. It sounds like your wife got the latter. She also seems to be...how should I put this...bending reality to suit her need. You know what's more dangerous for patient care than crappy notes? No notes. Kind of convinient how she ignored that aspect of it.

    In regards to 2...although this isn't "PC" and nobody in the program would be "officially" advocating this, the reality is that residents very frequently go over duty hours to finish paperwork. I know many residents who would officially "clock out" and then go to another floor of the hospital or go home to work on notes for a few hours. It's just what happens and just because your wife decided not to play the game doesn't mean she should stay employed, especially if she didn't play the game at the expense of not being able to do her job.

    Finally, with regards to the 1100 vs 500 patient encounters thing...although this may seem impressive to you, that isnt actually that many patients. Assuming she only spent half the year in outpatient clinic (which is kind of a big assumption considering it's family medicine, but I do understand some FM programs have significant inpatient time) 1100 patients is seeing 8-9 patients a day. If we really want to get crazy we could say maybe 10 a day, maybe less if she actually spent more months in clinic. That's certainly within the realm of doable and as a private practice FM physician she would be expected to likely double to triple that workload immediately (and get all her notes done that day).

    Also, seems kind of weird to me that any old person can run a query on how many patients and encounters everyone else is responsible for but maybe that's how your EMR is set up. Seems to be something that's ripe for misuse.

    As a smart guy and a small business owner, think about it from your perspective. If you had an employee that was a month behind on his work after you had repeatedly told them he needed to catch up and now needed an entire week just to redo work that he was supposed to have done before, how long would they be staying employed?
     
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  26. michaelrack

    michaelrack All In at the wrong time SDN Advisor 7+ Year Member

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    I agree with what others are saying except for this statement. It's quite possible that the Op's spouse could function satisfactorily if she found a position without an EMR or a partial EMR or one that let her dictate her notes for the EMR. This would limit her options. Of course, it is quite possible that her note writing problems are more global in nature.

    I do agree that it appears that the OP's spouse is not functioning satisfactorily as a resident and there are adequate grounds for termination.
    Being an adequate resident is not the same as being an adequate attending, but one has to get through residency first.
     
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  27. resident_spouse

    resident_spouse

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    >>The bottom line is...this is not a battle you can fight for your wife
    You are right. However, fact is that at the end of the day this is having an enormous impact on my life as well, I don't think it's fair to expect me to stand by idly as everything I have worked hard towards for years is being destroyed by someone else's decision...especially if they are entirely unwilling to explain their reasoning / respond to my wife's side of the story.

    I am still desperate to understand the circumstances; even if at the ends that means coming to terms with the fact she was fired for acceptable reasons. I did not post here to have people tell me whether or not my wife being terminated was right or wrong...I am much more interested in finding out what I can do to be able to get to a position to make that call. At this point in time, yes, I am choosing to believe my wife. I am very aware that it is probably impossible for me to ever be completely objective about the situation, but am at a loss as to how to even try to make an informed decision about how to act next when I am only able to get one side of the story.

    I understand that it is much more likely that there is another side of the story that paints a very different picture about how and why my wife has been fired. But just for the sake of argument, if you assume that my wife was terminated in bad faith, are there really no options than to pursue a lengthy legal battle? Does this highly regulated industry not have any other safe guards or advocates in place to prevent the exploitation? Considering the rest of the reality you find yourself in, is it that far fetched that exploitation and wrongdoing could actually exist in medicine or medical education?


    >> Being unable to understand as an outsider to medicine
    Although I do not work directly in healthcare, I do feel like I have a background rendering me at least somewhat proficient to ask some of these questions. Both my parents are doctors (granted, in a different country / a single payer system). I myself am, a software engineer / entrepreneur and have worked on multiple EMR systems for both doctors and dentists, so at the very least I understand very well what kind of information it is going into these systems and how the various pieces of information relate to each other.


    >> at the end of the day its about whether she was getting her work done
    Even if she was actually given an unreasonable workload? Even if she had batching privileges revoked and saw significantly more patients than any other residents? she saw almost twice as many patients last year as most other residents in her class. How can you fire someone for not getting their work done, when overall they are getting far more work done than anyone else?


    >> Comparisons to other residents / attempts to quantify via EMR
    Please help me understand how else to establish what a "reasonable" workload would be.


    >> If you had an employee that was a month behind on his work after you had repeatedly told them
    >> he needed to catch up and now needed an entire week just to redo work that he was supposed
    >> to have done before, how long would they be staying employed?

    The people I work with are knowledge workers (and I would consider doctors the same), as such I respect their intellect and opinions. If an employee had not communicated with me at all for a long time and then came along saying something like this..yes thats a problem; but if they had been voicing their concerns for months and I just kept piling stuff on top of their workload...I should probably blame myself and do whatever I can to help them.


    >> it seems that 1) she didn't want to write shorter notes because she believed it would "compromise patient care"
    what she did, was refuse to have other people dictate the content and time spent on notes, because ultimately she would be responsible for the contents of the notes.


    >> asking for "options to reduce workload", especially a week off is simply not an option
    My wife never say she needed a week, she said she could not manage the workload she was being assigned. I literally saw here maybe once or twice a week when she had a day off after being on call all night. otherwise she would get up at 5am, go to work, and come home around 10pm at which point me and the kids were usually asleep. I was getting upset at her working too much, felt like I was taking care of the kids by myself, thought she was just making excuses when she said that they would fire her if she didn't. She worked beyond 80 hours almost every week in the moths leading up to being fired...when she raised concerns about duty hour violations she was observing in other residents and herself...she was told that it was only because they spent too much time doing their documentation, and that they shouldn't count that time towards their duty hours in the first place.

    All because she choose not to sacrifice her integrity by being threatened into shutting up about her concerns? One of her evals, which otherwise are almost entirely positive, reads: "seems to think residents are overworked, starting to negatively impacting work ethic of other residents." She was the only one who dared speak up. Many of the other resident are international; being an immigrant myself, I understand that they are terrified to speak up given their visas depend on their employment.


    >> It's just what happens and just because your wife decided not to play the game doesn't mean she should stay employed
    Really? Really!?!? The more I talk to people in the medical field, the more I realize that this is actually the prevalent mindset! To be blatantly honest, I find this mentality absolutely repulsive! The thought that medicine, one of the most highly regarded professions in society, literally chooses to build its very foundation on, and encourages the idea that everyone has to go through years of utter submission and sacrifice is disgusting! Do you really believe that this is the one and only way to make sure someone is proficient enough to practice medicine?

    Am I that disconnected from reality, that the idea of treating some of the most highly educated people our society has to offer with respect and dignity sounds not only morally right, but like a good idea in terms of encouraging a culture of success and better outcomes?!
     
  28. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    To recap the consensus:

    1.) Timely and accurate documentation is an essential part of the job.

    2.) You cannot fight your wife's battles for her. Sending a letter or calling the program is entirely counterproductive, whether she sends the letter or you do.

    3.) Her best chance of surviving in medicine is trying to reconcile with her old residency - not become combative - and hope to get a lukewarm letter and recommendation that *may* allow her to reapply and start a different residency. Unfortunately, with the termination happening rather than resignation, the chances of reconciliation are slim.

    4.) If a career in clinical medicine is no longer in the cards, your wife may benefit from retaining a lawyer, but winning a case is very unlikely. The odds are stacked against residents and there would have to be truly egregious violations that could lead to a successful suit.
     
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  29. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING 5+ Year Member

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    To add, winning a case in this instance is very unlikely not only because the odds are stacked against residents but your wife has a history of not completing her work in a timely fashion that the program can point to. As was mentioned before, the only way you'd win this are on technicalities if the school happened to not follow their own procedures (or if you have an actual email from the PD saying they're giving her more work in response to her complaints or telling her to work over duty hours on her notes...I doubt any PD would be so irresponsible but if you have an actual email telling her to work over duty hours that could be a golden ticket for you as the ACGME is, on the surface, very strict about "official" duty hour restrictions right now).

    You're never going to be objective about this, as noted by your last post. You see her as "not sacrificing her integrity". Her PD (and the other attendings) see her as not getting her work done on time and refusing to write shorter notes for...some reason? That still isn't clear. I mean, saying she won't allow people to dictate the time she spends on notes is like going to work and saying "you can't dictate the time I spend on this project, if I need 6 months to get it done I'm gonna do it because I'm responsible for it!". There's a middle ground and it doesn't sound like she was reaching it, especially with evaluations noting her "negatively impacting the work ethic of other residents". Residency is not a time to be stirring up a revolution when you have a lot to lose...you have none of the power and all of the vulnerability.

    In reality, best case scenario is that everyone is extremely overworked and she tried to be a martyr (with not the most well-thought out plan it seems). If that really was the case, I'm sorry she was overworked and she may very well be in a malignant program full of IMGs that the program administrators know they have significant power over. Unfortunately, residency is not the time to be a martyr. She's in family medicine, not surgery, all she needed to do was tough it out for two more years and not ruffle any more feathers and she'd be an attending.
     
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  30. resident_spouse

    resident_spouse

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    Okay, I want to make sure I'm understanding this right:

    Most people here seem to be saying that even if, however unlikely it may be, my wife was truly fired unjustly,her only options are to either throw integrity out the window, or give up the idea of practicing medicine and starting a legal battle that is likely to go on for years.
     
  31. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    I would not cast things this way "either integrity lost or give up." Unfortunately, what we are taught early in medical school and what in theory is best for the patient does not happen in the real practice of medicine. Whether it's the outpatient clinic visit where only the top 1 or 2 issues can be addressed in 15 minutes with a cursory physical exam, or the busy ICU where the house staff does not have time to follow up on every routine lab at night and depends on nursing to pick up on it, we are given very limited time to get a lot done, and we have to prioritize. That's why much of the prior work of the physician is being transitioned to nursing and midlevels who have protocols in place that can be executed in a routine way.

    This also means that we must get documentation done in a timely manner. This is particularly important because of the increased shiftwork of medicine with increasing handoffs between physicians and patients going to a clinic for whichever doctor is available rather than their personal PCP of the past 20 years. It is more important for the documentation to be done and on the chart with the major points outlined than getting a verbose 4 paragraph HPI in and addressing every little detail. To do that takes on the order of an hour or more and is just not feasible given the number of patients managed in clinic and the ongoing needs of very sick patients on the floor or the unit.
     
  32. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    People are saying that she has, basically, four options right now. The odds of all of them are low, unfortunately. No one is saying that this is right or fair.

    #1. Find a way to reconcile with her program and be allowed to continue. Whether that involves "throwing her integrity out the window" is (I think) debatable and more than a little bit melodramatic.

    #2. Find a new residency program. For any reasonable chance at this, she will need at least a lukewarm letter of recommendation from her former program. All of your attempts at getting information/answers - especially your directly contacting the PD and other residents in the program - directly undermine any chance of this

    #3. Pursue legal means if there is a reasonable case that her termination was illegal/in violation of policy.

    #4. Pursue a different career

    I'm not expecting you to stand idly by. I'm expecting you to support your wife through reasonable avenues.

    Can you think of ANY field where a supervisor would respond positively to a spouse asking them why their employee was fired? It's completely inappropriate of you, a spouse, to be contacting her (former) bosses.
     
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  33. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    This response is a perfect example of why it is so important for you to keep yourself out of this process.

    Posters here have tried to (a) explain to you her options moving forward and (b) identify some specific problems that, from your posts, seem to have possibly contributed to why she was terminated.

    No one has cast judgment or given a response that would make your comments here anywhere close to appropriate.
     
  34. resident_spouse

    resident_spouse

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    All I did was sincerely and respectfully request some explanation; the only reason I did so, was because I have watched my wife do the same only to be blatantly ignored.

    Sounds like the situation really is as bleak as my wife has been saying; I guess I was hoping that she was being cynical or too pessimistic from being worn out and having to put up with this for the last 2 years.

    I can't find the words to describe the way this makes me feel about the medical community in this country at large.
     
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  35. resident_spouse

    resident_spouse

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    Can you give me an example of a reasonable avenue? I'm sorry, I really am not trying to be cynical...I just dont know what to do, which is why I came here in the first place I guess.
     
  36. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    I'll be blunt: it reflects poorly on the person in question (your wife) in the professional context when an outside person intrudes and tries to advocate on their part, including a husband, parent, child. You have a family relationship, not a working relationship, and even if you were an MD with experience, you would have no direct supervision to know about her competency. As it is, you aren't even in the field, which means you're even less qualified to make that judgment. The only "outsider" who can advocate for her in a way that would be helpful to her is an attending (ideally at the residency program) who has extensively worked with her and can contest the claims made against her. Such a person would also ideally have a good working relationship with the PD and might be able to argue for a second chance. As it is, there are very few who would be willing to do that (because of not wanting to make professional enemies) and even then, given the increasingly toxic relationship between your wife and the program, would be unlikely to succeed in getting her reinstated in her job. I think southernIM has outlined the options available to her best.
     
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  37. resident_spouse

    resident_spouse

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    I am sincerly appreciative of all the feedback and advice I am receiving. I was reacting to the following statement (which I don't think falls under either of the two categories you identify):
    But you are right about my reaction being inappropriate, I apologize. It (a) doesn't add any value (b) is overly cynical... It's just that it sounds like most people I talk to (not just on here) say something along the lines of "that sucks, but your supposed to work more than you can handle during residency, and keep quiet about anything questionable you may observe". I'm sorry, I don't think this is ethically defensible, and am shocked to find it so prevalent in what I believe to be a community with strong ethical values.
     
  38. SouthernSurgeon

    SouthernSurgeon Lifetime Donor 7+ Year Member

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    Exactly.

    It reflects incredibly poorly to have a spouse trying to intervene on her behalf. It's helicopter husbanding.

    I suspect, but do not want to assume, that to some degree this is cultural as OP has indicated they are both immigrants.

    When I said "appropriate avenues" what I meant were all the things one normally expects a spouse to do - be an emotional support, be a sounding board for discussion and ideas. There is no "appropriate avenue" for a husband to pursue this professionally.
     
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  39. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    It's not that I'm unsympathetic. I think many of us feel a ton of internal tension about the fact that we're expected to take care of critically ill patients with minimal knowledge about them - sometimes without even having personally examined the patient - or on the other hand engage in the human assembly line called primary care with the crappy physical exams, the closed-ended questions, the review of systems templated sheets the nurse hands out. It's just that if we don't adjust to the system and do the best we can, we're out of our job entirely. Once an attending, we can choose to see fewer patients for less pay, or work longer hours to be more thorough, or work abroad where the documentation is no where nearly as voluminous, but that's not a choice given to us in residency.
     
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  40. resident_spouse

    resident_spouse

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    >> It reflects incredibly poorly to have a spouse trying to intervene on her behalf. It's helicopter husbanding.
    I respect my wife, and hold her in nothing but the highest regard. I don't think that I am in any way shape or form in a better position than her to deal with this situation. Try to see it from her perspective though, she speaks up, her concerns, questions, requests are blatantly ignored...the people outside the program she has been trying to talk to, all dismiss her concerns almost immediately because obviously she must be at fault. The only ones who is willing to listen are attorneys; I guess I was just hoping that there was something else we could do so that we wouldn't have to go that route...the fact that some of these legal battles go on for 6+ years is just so bleak of an outlook to me...there is no way to recover these most formative years for my children, no matter how much money someone might award us 6 years down the line.

    I have two motivating factors:
    (a) I want to help my wife, whom I have watched go from outrage to pretty close to loosing any and all hope of finding someone who will listen.
    (b) trying to find any evidence to indicate my wife is exaggerating wildly, hiding something from me, or is in denial...i don't want my wife to be at fault...but at least I would understand.
     
  41. resident_spouse

    resident_spouse

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    This is exactly what I am talking about...dont you realize that you / we are "the system". both residents and attending see this happening, think its wrong, but just write it off as being part of "the system"? sorry...does not compute.


    I realize this is a highly regulated industry we are talking about...but, especially in terms of medical education it is very much self regulated as far as I can tell.
     
  42. resident_spouse

    resident_spouse

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    To attempt bringing this back on track:
    Can anyone suggest how to establish what a reasonable work load is ?
     
  43. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING 5+ Year Member

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    1) This isn't on track at all
    2) No matter what anybody on here thinks a "reasonable" work load is, it's not going to help you or your wife.
    3) Your wife is not going to win this battle by arguing she was worked too hard. Unless, as I mentioned before, she has something in writing telling her to go over duty hours, that's a fight you're not going to win.
     
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  44. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    This is neither here nor there. There is no pending class action suit. Residents have gotten the 80 work week, which in theory was supposed to reduce errors. I am grateful for the relief, but the internal tension is still there because there are numerous handoffs and I don't know the patients as well as I would with a system with greater continuity. I can't fight this, this is a systemic problem in medicine. The patients are sicker, more complex, and living longer. The patients treated as outpatients were previously inpatients. The inpatients were previously in ICUs. And the ICU patients would have just died in the past. Everyone has a job in this system. The nurse's job is to follow the patient closely, execute protocols, and notify me of any abnormalities - assuming this is a good nurse. My job is to respond to minor patient and nursing requests when I get to it, act on major events in a timely manner with medication, labs, imaging or procedures, get help with my seniors or consultants when indicated, document everything, and relay information to the person who takes over. If I see something egregious that is in someone else's "domain" I will discuss it with them and see about getting it changed. My job is not to do the job of everyone else who is following the patient. My job is not to cite in my progress note three articles in arcane ID journals on tuberculous meningitis when ID has been consulted, is following the patient, and providing recommendations anyway. Nor is it my job to solve the patient's pain during intercourse as the primary care doctor when she is seeing her gynecologist next week to get her IUD removed anyway. Of course, if there is no consultant or other subspecialist following the patient, then it IS my job to address those issues - by looking up the treatments and administering them myself or consulting or referring as appropriate. It seems your wife did not "get that," tried to do it all, write about everything exhaustively, and that's what played a large part in getting her terminated.
     
  45. resident_spouse

    resident_spouse

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    I'm not sure how me saying 'She did refuse to "just do them faster"', got turned into her bing OCD,"not getting it", or writing about everything exhaustively...

    Can anyone suggest how to establish what a reasonable work load is ?
    >> This isn't on track at all
    >> This is neither here nor there.

    ???
    if
    - overall you are getting more work done than your peers
    - are still being assigned more work than you can get done already doing little except eat, sleep, and work
    - are told to not worry about administrative issues and instead go finish your work when you are pointing out that you have too much work
    - finally get fired for not getting your work done

    I think its fair enough to ask what a reasonable workload is supposed to be....
     
  46. colbgw02

    colbgw02 Delightfully Tacky 10+ Year Member

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    Not by you and not on SDN.

    What I mean us, internet strangers can't answer that question. And the people who can don't want to hear it from a resident's spouse.
     
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  47. gutonc

    gutonc No Meat, No Treat SDN Administrator 10+ Year Member

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    You have not established here that this is the case. All you have to go on is your wife's word that this is true. And she is clearly not a dis-interested 3rd party.

    As to what constitutes a reasonable workload, it will vary between specialties and programs. But you need to understand that getting so far behind in your documentation that even a whole week off to catch up isn't enough is a major issue. As is the case in most of these scenarios, we only have one side of the story here and it's not even first hand.

    So, is it possible that your wife got completely hosed here and unfairly fired? Sure.

    Is that all there is to this story? Absolutely not.

    Can she recover from this? Maybe.

    Is she done at this program forever? Absolutely.

    Could she get a decent LOR from the PD in the hopes of applying elsewhere? Not if you send that ridiculous letter you posted or lawyer up.

    Will getting a lawyer involved help anything other than the lawyer's billable hours? No.

    Do you need to learn to use the quote function? Sweet baby jeebus yes.
     
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  48. resident_spouse

    resident_spouse

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    Your right. I'm sincerely sorry if I upset someone, I really need to stop posting at all. I'm sure evryeone here understand that this is an extremely frustrating situation to be in. If there is a moderator able to delete this entire thread I would be thankful, but understand if that is not possible / will have to take responsibility if it ends up coming back to bite.

    Thank you everyone, you don't know how much I appreciate everyones responses, even when most of they were not what I wanted to hear.
     
    Promethean likes this.
  49. Dral

    Dral 7+ Year Member

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    This proves that you just are not in tune with the way the medical profession works. You're not supposed to, so that's ok. Everyone is so quick to judge the medical profession, but I wish wish WISH everyone could walk in our shoes for a day and see all the pressures we deal with. I'm not saying we have the worst most stressful jobs. I may bitch about certain things, but I'm so glad I am where I am.

    There are duty hours. I don't want to condone working over the limits, but what are we supposed to do? There are patients to take care of, notes to write, PAs to call in, etc. The people who make these rules about duty hours, are, as far as I can tell, so far removed from any clinical duties, that they just don't get it. I'm not saying duty hour restrictions should not be in place, but what happens when these patients need to be taken care of? If a small community program has a certain number of patients to take care of, what happens when the load is too much for all the residents to handle? Do we just turn patients away and say we're too busy as it is? We can't...it's against our hippocratic oath. Do we just hire new residents? *Poof* here is more money from an already strained medicaid system to cover those residents' salaries.

    You see what I'm getting at? Residents all play by the hour logging 'rules' and log that they went 8 hours over duty...ACGME cracks down...probation for the program...again, do we turn patients away?...how do we handle the situation? The residency program gets shut down...NOW WHAT DO WE DO WITH ALL THOSE PATIENTS? Do you think programs make residents work so hard to be mean? Of course not!

    Sometimes people just log the hours at max allowable and know they will not log the extra hours after that to get their work done...it's to preserve the program, it's to preserve patient care, it's to preserve their careers. THAT is the game and people who play by THOSE rules get the job done and don't get into trouble.

    I'm lucky in that I'm in a specialty/program that doesn't come close to going over hours, so I log my hours honestly and it's all good (though I have come close to reaching limit on occasions).

    Calling how we do these things into question is opening up a whole Pandora's box that is best left alone....trust me.


    Now, with that out of the way, I honestly think the best approach is for you wife to go back to the program, try to make amends, and get a letter of support for a residency program elsewhere. However, I am not you or her, so you as a team need to decide what to do ultimately. It will boil down to how much she wants to become a boarded physician.
     
    Promethean likes this.
  50. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    Better if such threads aren't deleted because, although this situation usnt that common, I suspect the next spouse of a resident in your situation could benefit from reading this dialogue. I don't know that you put much in the way of identifying details on here that it will bite you, and if you did, the damage is likely already done.
     
    Winged Scapula likes this.
  51. Law2Doc

    Law2Doc 5K+ Member Moderator Emeritus 10+ Year Member

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    I think it's a fair game question. But I'm not sure OP is going to like the answer. there is no such thing as lockstep hours for residents. You will find cushy residencies where 60 hours is the norm, and less cushy ones where time cards curiously end up saying exactly 80 hours each week. the rules say you need to average no more than 80 hours a week averaged over a four week period. Could that mean well over 100 hours in a given week? Yes. There are also people who for various reasons, and sometimes even unbeknownst to the program, violate those hours, to see more cases, look like superstars on rounds, get their documentation done, etc. Shouldn't happen but it does. So how do you decide what's reasonable? Probably a ton. But your problem is that there's such a range. Your spouse may have felt like she was doing a lot compared to her co-residents but still have been eclipsed by the surgical intern across the street. Does his workload make hers reasonable? I suspect yes. But it's an interesting question.
     
    Last edited: 09.23.14

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