Termination from Residency

[rogerrabbit221]

I'm looking for advice, and trying to keep this vague.

My fiance in early yrs in a competitive surgical specialty and I fear they will be asked to leave soon. I believe the issues are related to politics and nursing relations, and this yr has been the busiest for their residency. They've been on probation and asked to prove themselves. The residency program is hinting they may not be able to stay. They've never had issues during med school, AIs, or PGY1. We have talked to lawyers and advice is variable.

We are struggling to figure out what options we have. I imagine options include:

1. Apply for the match again (more $$, waiting another year).

2. Look for open spot to restart at the same specialty but in different location (likely impossible given the competitiveness of this specialty).

3. Same specialty residency swap (but doubt program would approve if they're on probation).

4. Look for other surgical specialties outside of the match. Tried residency swap but openings are limited given how late it is in the yr. Do you just start cold-calling or emailing programs?

My fiance wants to do a surgery residency or nothing else. Hoping for advice and PMs on how a resident navigates this situation.

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[GoSpursGo]

Hard to advise given that we are getting information secondhand and it’s hard to know what issues are related to politics/nursing/etc. if they actually want advice it would help for them to come post themselves. There is a confidential expert advice forum at top of the forums where they could provide more information without it being public

However, by far the best path to being a practicing surgeon is for them to put their head down and figure out how to not get terminated. All surgical specialties are sufficiently competitive that they are not likely to Take a chance on someone that washed out elsewhere, so none of the 4 options you suggest are likely to be successful.

 

[rogerrabbit221]

Hard to advise given that we are getting information secondhand and it’s hard to know what issues are related to politics/nursing/etc. if they actually want advice it would help for them to come post themselves. There is a confidential expert advice forum at top of the forums where they could provide more information without it being public

However, by far the best path to being a practicing surgeon is for them to put their head down and figure out how to not get terminated. All surgical specialties are sufficiently competitive that they are not likely to Take a chance on someone that washed out elsewhere, so none of the 4 options you suggest are likely to be successful.

I don't think they're willing to post or in the right headspace. Most issues are related to communication/complaints from nurses, a delay on a VIP patient (that's when they got a major complaint at the beginning). No drugs or crime etc...

What if termination is inevitable?

I guess the other thing I can share is that they're in a 7yr residency. It's a malignant program. I was hoping there could be some success going to a 5 yr residency like gen surgery cause they still have enough funding?

 

[NotAProgDirector]

There's only one surgical sub which is 7 years long, and it's famous for being rather difficult.

You're correct about the funding. But the problem is that the funding isn't the actual problem. If they are getting complaints from nursing, perhaps the problem is a malignant environment. Or, the problem is your fiance. Finding a way to work well with nursing, rehab, admin, etc is part of being a physician. if they are having problems with this, other programs may be less inclined to take a risk that the problems will continue.

I'll also point out that if they are "not in the right headspace" to deal with this -- that's part of the problem. Their career is on the line.

 

[Dr.LeoSpaceman]

As others say, hard to provide much advice with limited detail. I will say, however, that the appropriate initial response to this information should not be "it's a malignant program and this is politics". There needs to be some real self-relfection--often with the help of a trusted mentor--to identify if there are correctable issues. Past history ("never had problems before") doesnt exclude the possibility of their being issues, as the responsibilities and visibility change dramatically once you hit PGY2+.

Also to add, even for this notoriously challenging subspecialty, it's a bit of a red flag if they're talking about going straight to non-renewal. Usually you're going to be put on probation/remediation and get a few chances. So either the program is absurdly malignant or there are significant issues.

 

[rogerrabbit221]

They are on probation; I forgot to mention that. And they have shown improvement based on evals. BUT we are by no means, putting our eggs in one basket and assuming they get to stay.

Maybe I worded my post wrong, but specifically, I am wanting advice on navigating the process after being terminated and getting into another residency.

Is it cold-calling departments, is it going through the Match process again? Is it waiting for a spot to open up in September when someone decides to leaves?

I find old posts on "I got terminated from xy residency but I am now in another specialty and much happier." How??

 

[Apollyon]

There is a discontinuity in your statements: your partner will only take surgery, nothing else, and you enquire as to getting into another residency.

There are a very few head scratching weirdness cases in the past (male ortho resident beat a woman with a baseball bat, went to rehab, got back into ortho IN THE SAME STATE, nothing hidden or unknown), but, you, essentially, can't expect your partner to get another surgical spot. Period, full stop.

 

[Dral]

Any potential new PD is going to want to hear from a prior PD. The likelihood of getting into another competitive specialty with a termination on your record is just not very likely at all. Sorry.

If termination is imminent, you could ask the program if you could resign instead. Resigning looks better than being terminated obviously. We had a surg sub resident here a few years ago who was not doing well. They successfully transitioned into a different nonsurgical specialty here (and did quite well in the new specialty I might add). Depending on the culture or attitude of the current program, they might even be able to write a neutral-ish letter to any new PD.

They'd probably be more willing to write a neutral-ish letter to another PD in another field. Think of it this way: If I'm an Ophtho PD on the east coast and have a resident not doing well and write a letter for a resdient for family medicine in the mid-west - if the resident doesn't do well in the family med program. Well, that sucks, but I, as the original PD, probably wouldn't hear too much about it.

Now, let's say I'm an Optho PD in NYC and have a resident not doing well and write a letter for Ophtho, the resident gets a spot in an Ophtho program in Boston but then doesn't do well. What do I, as the original PD, say to the other PD when I see them at meetings or other places and they come to me and say "What the heck, why didn't you warn me about this person"? This is especially true for smaller specialties (like surgical subs).

The way to navigate to a new specialty varies. Reapplying in the match or keeping an eye open for spots that become available are the main ways. Again, any new PD regardless of the specialty is almost certainly going to want a letter from a former PD.

If you step back and think about how this goes, especially for a competitive specialty:

Competitive specialty PD at other potential new program: Ok, this person was terminated due to not getting along with staff. That could very well happen here again - not taking a chance when I have all these other fresh faces with no issues (at least no proven/known ones).

Non-competitive or other specialty PD: Ok, this person was terminated due to not getting along with staff. There is somewhat of a possibility that it was related to the specialty. Maybe stress related or something not going right due to 'wrong fit' for their specialty. Maybe I can give them a chance here in this other specialty.

For all we know, it could be that their skills are not up to par, and this is how a program puts them under the scope to terminate them. I'm not saying that's the case, but it's something to consider. Either way, sorry you folks are going through this. I'm sure it's beyond stressful.

 

[comp1]

It is a huge detriment to a program to separate a trainee early. It messes up rotations, funding and ultimately clinical care in ways that can take years to recover from. It's also reported publicly and is a black mark against the program. It's all compounded in a long duration competitive residency. I get that it's much worse for the trainee, but it's not something that programs undertake because of minor personality disagreements with nurses or a decision made by one person. I strongly support the above poster that your partner needs to find a trusted mentor and do a significant degree of self reflection. It's somewhat disturbing that you're the one posting and not them though, it's making this all appear to either be wildly overblown or a fait accompli.

 

[NotAProgDirector]

As others have mentioned, there's no one clear path forward. Options include finding an open spot vacated by someone else, or entering the match again. Sometimes programs expand and that opens a spot off cycle. And specialty might be the same surgical sub, Gen surgery, or a non-surgical field.

It remains unclear what your partner's problem(s) are, and how much is due to them vs program vs "fit" (a combination of both). As their partner, you are unlikely to assess this in an unbiased manner. Any new program is going to want some assurance that the same issues won't arise again. And conflict with nursing is a problem that crosses into all fields -- so is very problematic.

Agreeing with others, another spot in a competitive surgical field is incredibly unlikely. Unless you have some political connection, and even with that, I expect that's not an option.

I am not able to say what their chances of a GS spot are. They would need to convince a program that whatever the issue was in the current program will not repeat. Details here are too vague (understandibly) to address that.

Transfers from a surgical specialty to medicine (and often a procedural fellowship) are not uncommon. Same with transfers to Anesthesia. But usually, the story is "poor spatial awareness" or "klutz in the OR" or "just doesn't enjoy operating". because all of those issues go away in these other fields.

So bottom line, your partner needs to own this problem and find a solution. I can only imagine how difficult this is for you to watch unfold. You can (and should) support them. But they need to figure this out.

 

[Crayola227]

There is a discontinuity in your statements: your partner will only take surgery, nothing else, and you enquire as to getting into another residency.

There are a very few head scratching weirdness cases in the past (male ortho resident beat a woman with a baseball bat, went to rehab, got back into ortho IN THE SAME STATE, nothing hidden or unknown), but, you, essentially, can't expect your partner to get another surgical spot. Period, full stop.

I mean it does make sense as far as continuity, the resident might think "surgery or nothing" but what's that to the spouse? That probably seems crazy, given everything the resident and no doubt the spouse has invested so far. No doubt the spouse is thinking wtf and busy looking at what to do next, even if their spouse is still in denial.

It's a tough situation for sure.

 

[rogerrabbit221]

Thanks for most of the advice. Some of the skepticism... I don't appreciate.

The reason I'm posting is because my fiance's life has been consumed by work, sleep, and more work. I have much more time on my hands, so I want to help as much as I can and gather information.

Of course if it were me, I'd probably take any residency spot but they have different ideas on what is a fulfilling career in medicine.

 

[AlbinoHawk DO]

I'm going to be really forward with you and tell you that if their options are surgery or nothing else, then they will get nothing else. Let's assume for one that you're right that this is entirely because the program is malignant and there were politics involved. The PD will not write a letter of support for this person. No program is going to take a chance on this person in any competitive specialty. Why would they when there's a 1000 CVs (not an exaggeration) without baggage banging at the door?

If he were to apply to Family Medicine or perhaps Emergency Medicine, then maybe there is a program that will take a chance because of their MD and their good scores. This program will probably not be a university based program and will probably be full on FMGs/IMGs in a community nobody wants to live in, which could very well be malignant too. This is your best option as being a board certified physician in any field is a million times better than being a terminated doctor.

Right now, he should be gathering letters of recommendation from faculty who like him. If he completed a PGY1 in another specialty, even as prelim, getting a recommendation from that program director can be immensely helpful.

Be very upfront with your fiancé. They are facing end of medical career with no way of going back circumstances. They're a "salvage title" and should approach what they do next with this mindset

 

[rogerrabbit221]

I've heard stories of people continuing in another surgical residencies, but okay, that is not realistic.

Would anesthesiology or radiology be viable specialties? Or are the only options the least competitive - family medicine, EM, or internal medicine?

 

[LucidSplash]

I've heard stories of people continuing in another surgical residencies, but okay, that is not realistic.

Would anesthesiology or radiology be viable specialties? Or are the only options the least competitive - family medicine, EM, or internal medicine?

Stories, or you know people personally and the exact circumstances?

In many cases, it is not realistic for a resident terminated from a surgical specialty for cause to continue in another surgical residency. Yes, occasionally someone beats the odds. However, as has been explained to you, the exact circumstances of leaving a surgical program, which we don’t have access to here, are important for assessing the chances of finding a new surgical training spot. Most people who are able to bridge the gap have strong support from their first program. So it is not inappropriate to tell you that in general the chances are likely slim to none.

Surgery residents do move to radiology and anesthesia. But generally when they are residents in good standing who decide surgery is not for them and leave of their own volition. They typically have the support of their surgery program to find another spot. It would be much less likely to find one of these spots if a resident was terminated for <reasons>.

 

[eyeeye_captain]

I've heard stories of people continuing in another surgical residencies, but okay, that is not realistic.

Would anesthesiology or radiology be viable specialties? Or are the only options the least competitive - family medicine, EM, or internal medicine?

Correct, this isn’t the usual situation where a transfer makes sense. A fired resident doesn’t get another shot at surgery, unless as above, there are extraordinary circumstances that make it happen.

Similarly, yes, anesthesia and radiology are possible, but your fiancé should probably resign (because both are competitive enough that a termination is fatal), find a way to discuss why the current field didn’t work and why the new one is up their alley, and then have to play the match/waiting game. A good number of those switches happen within the same institution (and at this point it’s the only way to avoid a dead year), but with bridges burned on both sides, I highly doubt that’s going to happen. That means at least a year off. It’s significantly easier to try to jump into a program like IM/FM/EM, maybe peds or occupational med where spots are hanging open. Even then the PD is going to have to play ball, so keep their head in the game for the next 2 months or things get tougher.

Honestly, the goal now isn’t surgery, as you can see. It’s to not have the diploma as a nice paperweight. There are some rinky dink jobs you can get with an intern year and a Step 3 pass. They’re not nearly as good as finding a new residency.

 

[Dr.LeoSpaceman]

Thanks for most of the advice. Some of the skepticism... I don't appreciate.

The reason I'm posting is because my fiance's life has been consumed by work, sleep, and more work. I have much more time on my hands, so I want to help as much as I can and gather information.

Of course if it were me, I'd probably take any residency spot but they have different ideas on what is a fulfilling career in medicine.

The fact that you are trying to help by gathering information is commendable. He is absolutely going to need that support to get through this process. But I'm going to throw out an analog to what I said before: The best thing you can do for him is to convince him to be proactive and realistic about figuring out his next move. If he feels too busy/tired/unmotivated to figure out what the next step is (and how to get there), that's an enormous barrier. It's literally step one, and if he doesn't get serious, any information we provide (or you gather) isn't going to help.

 

[AlbinoHawk DO]

I've heard stories of people continuing in another surgical residencies, but okay, that is not realistic.

Would anesthesiology or radiology be viable specialties? Or are the only options the least competitive - family medicine, EM, or internal medicine?

Personally, I would say that anesthesia and radiology are not realistic either. He's a terminated resident with no program support. Those specialties are competitive even if not as much as surgical subspecialties.

Right now, your fiance is basically fighting for a program known to match poorly or not at all to give him a chance. He'll only get that with FM or EM. I can tell you for a fact that I've met IM PDs who will explicitly say they rather go unmatched than match a problem because they know that in SOAP they can easily catch someone who failed to match a competitive specialty because they know that person will prefer IM in hopes to become cardio or GI

Talk to your fiance out of jumping into the void. His mistakes will result in direct relationship problems down the road when he's unable to secure a well paying job

 

[AlbinoHawk DO]

Correct, this isn’t the usual situation where a transfer makes sense. A fired resident doesn’t get another shot at surgery, unless as above, there are extraordinary circumstances that make it happen.

Similarly, yes, anesthesia and radiology are possible, but your fiancé should probably resign (because both are competitive enough that a termination is fatal), find a way to discuss why the current field didn’t work and why the new one is up their alley, and then have to play the match/waiting game. A good number of those switches happen within the same institution (and at this point it’s the only way to avoid a dead year), but with bridges burned on both sides, I highly doubt that’s going to happen. That means at least a year off. It’s significantly easier to try to jump into a program like IM/FM/EM, maybe peds or occupational med where spots are hanging open. Even then the PD is going to have to play ball, so keep their head in the game for the next 2 months or things get tougher.

Honestly, the goal now isn’t surgery, as you can see. It’s to not have the diploma as a nice paperweight. There are some rinky dink jobs you can get with an intern year and a Step 3 pass. They’re not nearly as good as finding a new residency.

I would say that at this point if they feel termination is inevitable it would be best to go to the PD and tell them the intention is to quit. Tell the PD they can submit the letter immediately and write in the letter that they will be available the ret of the year as to not disrupt any of their plans for the academic year. This small move could be enough to get the PD to at least have mercy into writing a neutral letter of recommendation.

 

[Apollyon]

"The skepticism....I don't appreciate"

That is part of the problem, right there - "I don't want to hear the bad news". Well, there it is.

 

[rogerrabbit221]

"The skepticism....I don't appreciate"

That is part of the problem, right there - "I don't want to hear the bad news". Well, there it is.

"There is a discontinuity in your statements" is what I'm referring to as the skepticism, like this post is fake. Not relevant to what I had asked about.

 

[LucidSplash]

"There is a discontinuity in your statements" is what I'm referring to as the skepticism, like this post is fake. Not relevant to what I had asked about.

The discontinuity refers to something we often see here on SDN: the gradual release of information over several posts, which slowly add more context but also reveals more negative information about the poster or loved one over time. Forgetting to mention that someone is on probation is a pretty big thing to forget. Based on your post history, we know you are also a physician, so it is not unreasonable to assume you should be able to understand that being on probation is not a small thing. Neither are repeated issues with nursing or institutional politics. No one is being “skeptical” here, they are telling you that the details are key and you can’t reasonably expect the best information without revealing all the details.

Your loved one doesn’t have to worry about being doxxed, this story is a dime a dozen on SDN if you do a search.

 

[2020OU]

I get that it's much worse for the trainee, but it's not something that programs undertake because of minor personality disagreements with nurses or a decision made by one person. I strongly support the above poster that your partner needs to find a trusted mentor and do a significant degree of self reflection.

It absolutely can be because of a decision by one person. However, those are the cases that it is easier to bounce back. It is where there are only one or two people behind it where the resident has been able to beat the odds and done well in the end. No recovery from termination is easy, even for those residents.

It could be multifactorial. For example, there is one area of weakness in combination with the chairman doesn't like you so a case is manufactured. Or maybe the resident is a minority, obese, Muslim, LGBTQIA2S+ (forgive me if I left out some letters), or wrongly suspected of being LGBT so they are punished for one area of weakness more than another resident who did worse.

 

[dozitgetchahi]

It absolutely can be because of a decision by one person. However, those are the cases that it is easier to bounce back. It is where there are only one or two people behind it where the resident has been able to beat the odds and done well in the end. No recovery from termination is easy, even for those residents.

It could be multifactorial. For example, there is one area of weakness in combination with the chairman doesn't like you so a case is manufactured. Or maybe the resident is a minority, obese, Muslim, LGBTQIA2S+ (forgive me if I left out some letters), or wrongly suspected of being LGBT so they are punished for one area of weakness more than another resident who did worse.

Yes.

I don’t want to go into crazy details on this - but when I was a rheumatology fellow, my program had a habit of choosing one fellow a year that was sort of the “dunce”. I.e, the one they chose to pick on and give an unwarranted hard time.

The first year I was there, the “dunce” was the only Hispanic fellow they had ever had in the program. The second year, the “dunce” was the only *male* fellow they had out of six at the time (all other fellows were female, and probably 2/3 of the attendings were female also). And neither really deserved it. And I have absolutely heard of programs where an LGBT trainee was given a hard time, because being LGBT didn’t mesh with the “high Christian” values of the dept leadership. So it’s a real thing.

 

[AlbinoHawk DO]

The discontinuity refers to something we often see here on SDN: the gradual release of information over several posts, which slowly add more context but also reveals more negative information about the poster or loved one over time. Forgetting to mention that someone is on probation is a pretty big thing to forget. Based on your post history, we know you are also a physician, so it is not unreasonable to assume you should be able to understand that being on probation is not a small thing. Neither are repeated issues with nursing or institutional politics. No one is being “skeptical” here, they are telling you that the details are key and you can’t reasonably expect the best information without revealing all the details.

Your loved one doesn’t have to worry about being doxxed, this story is a dime a dozen on SDN if you do a search.

Also, being on probation makes one wonder what really is going. Most programs will first issue some type of "warning" letter to the resident. If this doesn't work, they go for an improvement plan. If that fails, they go for remediation. Probation is the last step before termination. Jumping straight to it would require a lot of evidence against the resident. They would have to have reports from multiple nurses and staff. It would be highly unusual for the nursing department to join in with the program to target a fellow if the problem is only how malignant the program is

 

[Crayola227]

Also, being on probation makes one wonder what really is going. Most programs will first issue some type of "warning" letter to the resident. If this doesn't work, they go for an improvement plan. If that fails, they go for remediation. Probation is the last step before termination. Jumping straight to it would require a lot of evidence against the resident. They would have to have reports from multiple nurses and staff. It would be highly unusual for the nursing department to join in with the program to target a fellow if the problem is only how malignant the program is

Yeah I don't think this is strictly true everywhere. Sorry to be nitpicky.

You are correct generally a warning is given first, before the PIP, but it doesn't have to be anything egregious. The PIP *can* be the letter/warning if it's more serious.

Part of the PIP almost by definition is a remediation plan (or other corrective measures if in a different industry), which has some sort of probation period laid out in the PIP, at minimum it must have a time to review the period, so for all intents that is a probationary period. This may or may not be called probation officially, and it can be handled different ways by different programs at least on that piece. Some programs probation is reported to the medical board, and other times it is not.

As has been explained to me not only in medicine but by HR people outside our industry as well. It's HR legalities in firing an employee 101 unless something so egregious they can can you right off.

These are often not given in sincerity either, but to check the box for the "fair" firing.

Of course, employers don't always follow these rules as you'll always see here. That does open them up to wrongful termination cases or unemployment claims, but that still doesn't mean they handle it correctly and often claims aren't brought even if so.

My partner has been a manager and HR for multiple businesses for close to a decade in construction/trucking so he's definitely dealt with some **** offs to **** ups. And also in managing our construction business now. My aunt was also manager for a large company for 20 years and did HR. My best friend runs an HR department in a similar industry. I have also worked with more than one HR dept or related dept on disability accommodations and the like in medicine. Couple with about 10 years of PMs with residents on this. If nothing else they tend to be decent reporters on, did they get a PIP, what was the remediation plan therein, even if they don't tell me all or have insight into their issues.

Also we know that residency remediation plans can be sorely lacking, especially if it's a formality. Some programs are better or more genuine in this process. A single warning letter if given, then a PIP, can be followed by perfunctory effort as part of justifying a termination, not avoiding it.

That said, yes, generally there is a serious performance issue going on that initiates these proceedings. The resident here isn't denying severe depression.

 

[Crayola227]

Yes.

I don’t want to go into crazy details on this - but when I was a rheumatology fellow, my program had a habit of choosing one fellow a year that was sort of the “dunce”. I.e, the one they chose to pick on and give an unwarranted hard time.

The first year I was there, the “dunce” was the only Hispanic fellow they had ever had in the program. The second year, the “dunce” was the only *male* fellow they had out of six at the time (all other fellows were female, and probably 2/3 of the attendings were female also). And neither really deserved it. And I have absolutely heard of programs where an LGBT trainee was given a hard time, because being LGBT didn’t mesh with the “high Christian” values of the dept leadership. So it’s a real thing.

Yes, I have first hand knowledge of several residents from one program explaining seeing this exact thing over years, as well as witnessing it more than once. It happens for sure. Happens more often than people get canned for it, sure.

 

[LucidSplash]

Yes, I have first hand knowledge of several residents from one program explaining seeing this exact thing over years, as well as witnessing it more than once. It happens for sure. Happens more often than people get canned for it, sure.

Agreed.

That being said, none of this matters for the OP. Would recommend we not get lost in the weeds with rehashing things that have been discussed on similar threads in the past, as the whys and hows of the various ways people can be terminated are not that important or helpful for this particular OP.

 

[AlbinoHawk DO]

Yeah I don't think this is strictly true everywhere. Sorry to be nitpicky.

You are correct generally a warning is given first, before the PIP, but it doesn't have to be anything egregious. The PIP *can* be the letter/warning if it's more serious.

Part of the PIP almost by definition is a remediation plan (or other corrective measures if in a different industry), which has some sort of probation period laid out in the PIP, at minimum it must have a time to review the period, so for all intents that is a probationary period. This may or may not be called probation officially, and it can be handled different ways by different programs at least on that piece. Some programs probation is reported to the medical board, and other times it is not.

As has been explained to me not only in medicine but by HR people outside our industry as well. It's HR legalities in firing an employee 101 unless something so egregious they can can you right off.

These are often not given in sincerity either, but to check the box for the "fair" firing.

Of course, employers don't always follow these rules as you'll always see here. That does open them up to wrongful termination cases or unemployment claims, but that still doesn't mean they handle it correctly and often claims aren't brought even if so.

My partner has been a manager and HR for multiple businesses for close to a decade in construction/trucking so he's definitely dealt with some **** offs to **** ups. And also in managing our construction business now. My aunt was also manager for a large company for 20 years and did HR. My best friend runs an HR department in a similar industry. I have also worked with more than one HR dept or related dept on disability accommodations and the like in medicine. Couple with about 10 years of PMs with residents on this. If nothing else they tend to be decent reporters on, did they get a PIP, what was the remediation plan therein, even if they don't tell me all or have insight into their issues.

Also we know that residency remediation plans can be sorely lacking, especially if it's a formality. Some programs are better or more genuine in this process. A single warning letter if given, then a PIP, can be followed by perfunctory effort as part of justifying a termination, not avoiding it.

That said, yes, generally there is a serious performance issue going on that initiates these proceedings. The resident here isn't denying severe depression.

None of this that you write is accurate for medicine. There are very strict definitions for each one, and there are very strict distinct periods. Bypassing steps requires very egregious actions. You can't say that a warning letter is also an improvement plan, which also makes it a remediation and probation. It doesn't work that way. Please familiarize yourself with ACGME rules before you push misinformation.

 

[NotAProgDirector]

Actually, there is very little about remediation processes in the ACGME requirements. The only thing I see (looking at common PR's, institutional PR's, and IM's PR's) is this:

Residents who are experiencing difficulties with achieving progress along the Milestones may require intervention to address specific deficiencies. Such intervention, documented in an individual remediation plan developed by the program director or a faculty mentor and the resident, will take a variety of forms based on the specific learning needs of the resident. However, the ACGME recognizes that there are situations which require more significant intervention that may alter the time course of resident progression. To ensure due process, it is essential that the program director follow institutional policies and procedures.

If you know of more, I'm interested in reviewing.

 

[LucidSplash]

None of this that you write is accurate for medicine. There are very strict definitions for each one, and there are very strict distinct periods. Bypassing steps requires very egregious actions. You can't say that a warning letter is also an improvement plan, which also makes it a remediation and probation. It doesn't work that way. Please familiarize yourself with ACGME rules before you push misinformation.

While I am very aware that there are certain rules for ACGME, @Crayola227 isn’t completely off base. The “rules” are pretty vague. I have been both witness to (in others) and the recipient of, times in training when programs had a rather broad interpretation of the “rules” surrounding remediation and probation and termination of residents. So while it is good you have not experienced this personally, and certainly not every program has these issues, they absolutely do exist. Please do not be dismissive of the lived experience of others in this way, it is not helpful. Training programs are largely supportive environments but malignant ones that flout the norm do exist. To suggest otherwise is simply ignorant.

Now, the vast majority of SDN posters who come to SDN seeking guidance on this topic are ultimately revealed to have serious professionalism or performance issues. But truthfully it doesn’t take much to become a program’s “problem child” for reasons other than professionalism or performance, in certain circumstances.

Again, none of this is germane to the topic for the OP though.

 

[AlbinoHawk DO]

While I am very aware that there are certain rules for ACGME, @Crayola227 isn’t completely off base. The “rules” are pretty vague. I have been both witness to (in others) and the recipient of, times in training when programs had a rather broad interpretation of the “rules” surrounding remediation and probation and termination of residents. So while it is good you have not experienced this personally, and certainly not every program has these issues, they absolutely do exist. Please do not be dismissive of the lived experience of others in this way, it is not helpful. Training programs are largely supportive environments but malignant ones that flout the norm do exist. To suggest otherwise is simply ignorant.

Now, the vast majority of SDN posters who come to SDN seeking guidance on this topic are ultimately revealed to have serious professionalism or performance issues. But truthfully it doesn’t take much to become a program’s “problem child” for reasons other than professionalism or performance, in certain circumstances.

Again, none of this is germane to the topic for the OP though.

Malignant programs exist. I know because I was in a malignant program, yet I also know that they have institutional policies and that the ACGME requires for these to exist. It's not as easy some of you make it appear that you go straight into probation without any steps in between, unless an egregious situation has happened, or there being some form of due process

This is not about "lived experience." This is about policies, rules, and laws that institutions and programs are bound to.

https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformatted-requirements/cprresidency_2025_reformatted.pdf

"The program director must ensure the program’s compliance with the Sponsoring Institution’s policies and procedures related to grievances and due process, including when action is taken to suspend or dismiss, or not to promote or renew the appointment of a resident. "

Your argument is very suggestive that the program itself has no guardrails in regards of what they can and cannot do. I don't think there's either any institution out there without explicit policies regarding this because of how it opens them up to liability. As I said, it would be highly unusual for institution to jump straight into a probation to termination situation.

Actually, there is very little about remediation processes in the ACGME requirements. The only thing I see (looking at common PR's, institutional PR's, and IM's PR's) is this:

If you know of more, I'm interested in reviewing.

If you read it carefully, you can see the ACGME is giving leeway in case of scenarios that they cannot predict. However, there needs to be institutional protocol for these. It doesn't fall all on the hands of the program to do whatever they want. For example, here's one institutions policies regarding these situations: https://medschool.vcu.edu/media/med...ismissalPolicyFINAL_GMECapproved6.14.2022.pdf

In their case, "Probation may be initiated in two instances: i. When the specific expectations and plan of remediation noted in a letter of concern is not successfully completed by the trainee ii. When a clinical deficiency or behavior in question is sufficiently severe, in the absence of a prior letter of concern."

I don't think there would be any training institution without policies like this. It would open them to real liability

 

[NotAProgDirector]

I think we're all arguing the same thing.

There is little in the ACGME rules other than "the institution must have a process".

Legally, the standard is "Notice of deficiencies and an opportunity to cure".

Some institutions will have a solid, step wise process with real checks and balances. Others will have a less robust process that may offer little protection to residents. Even when the process is solid, much weight is given to the program's assessment of the resident's performance. If I was on an appeal panel for a surgical resident who was terminated for poor OR skills, it would take quite a bit of evidence to override the PD's assessment of the resident's poor skills.

In the example above, there's no definition about what is "sufficiently severe" to jump right to probation. Nor is there any definition of how long a resident must be given after a letter of concern. This is by design, to give programs flexibility to do the right thing. But it also opens the door to draconian decisions.

The process is honestly based upon the assumed good intentions of all those involved.

 

[LucidSplash]

Malignant programs exist. I know because I was in a malignant program, yet I also know that they have institutional policies and that the ACGME requires for these to exist. It's not as easy some of you make it appear that you go straight into probation without any steps in between, unless an egregious situation has happened, or there being some form of due process

This is not about "lived experience." This is about policies, rules, and laws that institutions and programs are bound to.

https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformatted-requirements/cprresidency_2025_reformatted.pdf

"The program director must ensure the program’s compliance with the Sponsoring Institution’s policies and procedures related to grievances and due process, including when action is taken to suspend or dismiss, or not to promote or renew the appointment of a resident. "

Your argument is very suggestive that the program itself has no guardrails in regards of what they can and cannot do. I don't think there's either any institution out there without explicit policies regarding this because of how it opens them up to liability. As I said, it would be highly unusual for institution to jump straight into a probation to termination situation.



If you read it carefully, you can see the ACGME is giving leeway in case of scenarios that they cannot predict. However, there needs to be institutional protocol for these. It doesn't fall all on the hands of the program to do whatever they want. For example, here's one institutions policies regarding these situations: https://medschool.vcu.edu/media/med...ismissalPolicyFINAL_GMECapproved6.14.2022.pdf

In their case, "Probation may be initiated in two instances: i. When the specific expectations and plan of remediation noted in a letter of concern is not successfully completed by the trainee ii. When a clinical deficiency or behavior in question is sufficiently severe, in the absence of a prior letter of concern."

I don't think there would be any training institution without policies like this. It would open them to real liability

That was a lot of words to try to tell me that I haven’t experienced what I have experienced.

Look I’m not some disgruntled fired resident. I was never fired. I was put on probation and made to repeat a year of residency for a poor inservice score during a time of significant family issues, where a family member was living on my couch, even though inservice scores are not supposed to be used for promotion in isolation. I had fantastic evaluations and was told I was the best resident in research that they’d ever had and that I had surgical decision-making beyond my PGY level. But I was also a liberal female Yankee in a southern surgical program who was not afraid to speak up when I saw overt racism, sexism, or homophobia.

I also witnessed a resident be fired without pretty much any probation period when I was a fellow in another program. Truthfully he was terrible and likely needed to go at some point. But policies were not followed. It was egregious and clearly not consistent with the processes in place. And yet it happened.

I’ve been in practice almost 6 years, am double board certified, and I have an additional masters, and I am involved in resident education. So this isn’t sour grapes or making up some story to justify my own shortcomings, or someone with no understanding of the admin side of resident education.

Yes, there are institutional policies. Yes there are ACGME “rules.”
The interpretation and enforcement of both ACGME and individual institutional policies varies VERY widely.

All I am asking here is that you accept that bad **** sometimes goes down and institutions can suffer zero consequences because they know how to game the system, and that I, and others, have personally lived through that.

MOST of the time, that isn’t the case. Most of the people that are terminated have serious professionalism and/or performance issues. But there’s a lot of things you can “document” to meet the bare minimum requirements if a program decides to get rid of someone.

 

[AlbinoHawk DO]

I think we're all arguing the same thing.

There is little in the ACGME rules other than "the institution must have a process".

Legally, the standard is "Notice of deficiencies and an opportunity to cure".

Some institutions will have a solid, step wise process with real checks and balances. Others will have a less robust process that may offer little protection to residents. Even when the process is solid, much weight is given to the program's assessment of the resident's performance. If I was on an appeal panel for a surgical resident who was terminated for poor OR skills, it would take quite a bit of evidence to override the PD's assessment of the resident's poor skills.

In the example above, there's no definition about what is "sufficiently severe" to jump right to probation. Nor is there any definition of how long a resident must be given after a letter of concern. This is by design, to give programs flexibility to do the right thing. But it also opens the door to draconian decisions.

The process is honestly based upon the assumed good intentions of all those involved.

You definitely make some valid points here in regards that there is leeway when it comes to these things set forth by the rules themselves. However, my point is that there is usually a process that is involved. Obviously, I can't know what is going on with the person who's facing this probation right now. Nevertheless, I am suspicious of a jump straight to probation then termination by way of how things are set forth here.

I know I'm entirely speculating at this point, but I really do become skeptical in this scenario because I don't see any benefit for the program to get rid of a resident or for the nursing staff to just jump in with the malignant program to target a resident if nothing happened. Therefore, I'm skeptical that this came from nowhere and that they jumping to a fast-track of termination

That was a lot of words to try to tell me that I haven’t experienced what I have experienced.

Look I’m not some disgruntled fired resident. I was never fired. I was put on probation and made to repeat a year of residency for a poor inservice score during a time of significant family issues, where a family member was living on my couch, even though inservice scores are not supposed to be used for promotion in isolation. I had fantastic evaluations and was told I was the best resident in research that they’d ever had and that I had surgical decision-making beyond my PGY level. But I was also a liberal female Yankee in a southern surgical program who was not afraid to speak up when I saw overt racism, sexism, or homophobia.

I also witnessed a resident be fired without pretty much any probation period when I was a fellow in another program. Truthfully he was terrible and likely needed to go at some point. But policies were not followed. It was egregious and clearly not consistent with the processes in place. And yet it happened.

I’ve been in practice almost 6 years, am double board certified, and I have an additional masters, and I am involved in resident education. So this isn’t sour grapes or making up some story to justify my own shortcomings, or someone with no understanding of the admin side of resident education.

Yes, there are institutional policies. Yes there are ACGME “rules.”
The interpretation and enforcement of both ACGME and individual institutional policies varies VERY widely.

All I am asking here is that you accept that bad **** sometimes goes down and institutions can suffer zero consequences because they know how to game the system, and that I, and others, have personally lived through that.

MOST of the time, that isn’t the case. Most of the people that are terminated have serious professionalism and/or performance issues. But there’s a lot of things you can “document” to meet the bare minimum requirements if a program decides to get rid of someone.

I can't tell you that you haven't experienced what you have experienced, and i wasn't intending to say that. I'm sorry that you had to go through that situation.