to resign or be fired

[JackADeli]

That's the ideal but we all know that there are some very malignant and vindictive even deceptive personalities in medicine who can hardly care if they destroy other people's careers for their own personal reasons and nothing to do with your performance...

Yes, I agree there are some individuals and some programs...

I agree there are some circumstances in which people suffer injustice and are improperly terminated. I do not know the specific circumstances of the OP or you...

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[NotAProgDirector]

Dr. Wang did it the wrong way and may be the wrong person. But still had the courage to bring someone to justice.

This statement, IMHO, is completely unacceptable. Shooting unarmed people in cold blood is neither courageous nor just.

Welcome to my blocked list. It was nice knowing you.

 

[Cleavername]

We can argue as much as possible, and we can bring numerous exceptional cases too. But I find it extremly unfair and extremely difficult situation for a fired resident to have a different career.

You can say one can be fired from college or School, even in the ist yr of residency let me say which is again very unfair.

But if someone had internship, 2nd year and in the end you fire him or her , and telling ,,that you are not a good fit for medicine is not true and not fair by any circumstances, unless the patient care or negligence is involved and you expect a resident as superhuman. so in that case you may justify firing someone.
But terminating someone.. it is definetly with intension to kill his or her carreer..and these people do not care. Someone has to act to bring them to justice one way or another.
Dr. Wang did it the wrong way and may be the wrong person. But still had the courage to bring someone to justice.
All of us know very well, how easy it is in the Residency programs for superiors to bring someone down.

how did that case end?

sorry i dont mean to cut in on this doctors forum when i am just an undergrad . but this thread has been nothing short of a good read.

 

[JackADeli]

...Dr. Wang did it the wrong way and may be the wrong person. But still had the courage to bring someone to justice...

I was unaware of DrWang specifics until AProgDir provided the reference. I find your statement obscene. Going "postal" does not equate to bringing "someone to justice". I find all this "victim" culture on SDN quite surprising. I also find the so called "victims" then referencing what is at the very least a "presumed guilty" scenario as "justice" to be apalling.

We don't know the truth or actual facts of anyone coming onto this forum crying victim and "woe is me". We definately do not know the truth or facts of a physician's dismissal in a wrongful termination suit, filed in court, who then proceeds to murder those he blames for his misfortunes. At the very least, I would be concerned about someone's mental stability/competence to be trusted practicing medicine if they are going to go postal. If nothing else, the murderers actions may provide further validity that he/she was unfit. It does NOT, I repeat, does NOT represent "justice".

Individuals that find themselves in a professional bind, in whatever career, are more likely to get out by taking a life inventory and accepting some modicum of responsibility/accountability as opposed to assuming victim roles and presuming assumptions that everyone is equally victims and thus band together, etc into this mob hysteria.

 

[zihuatanejo]

I was unaware of DrWang specifics until AProgDir provided the reference. I find your statement obscene. Going "postal" does not equate to bringing "someone to justice". I find all this "victim" culture on SDN quite surprising. I also find the so called "victims" then referencing what is at the very least a "presumed guilty" scenario as "justice" to be apalling.

We don't know the truth or actual facts of anyone coming onto this forum crying victim and "woe is me". We definately do not know the truth or facts of a physician's dismissal in a wrongful termination suit, filed in court, who then proceeds to murder those he blames for his misfortunes. At the very least, I would be concerned about someone's mental stability/competence to be trusted practicing medicine if they are going to go postal. If nothing else, the murderers actions may provide further validity that he/she was unfit. It does NOT, I repeat, does NOT represent "justice".

Individuals that find themselves in a professional bind, in whatever career, are more likely to get out by taking a life inventory and accepting some modicum of responsibility/accountability as opposed to assuming victim roles and presuming assumptions that everyone is equally victims and thus band together, etc into this mob hysteria.

I believe that much of the anger and feelings of powerlessness by residents often communicated by residents on this board is not necessarily based on "victimhood" as you put it, but rather it is based on the enormous power differential between residents and program directors wherein a program director can in some cases destroy a resident's career if they choose to for reasons that are suspect and not based on performance or objective criteria. I agree that it is unacceptable and ultimately self-destructive to commit illegal or immoral acts such as "going postal" as a means of exacting retribution, but I can appreciate how someone in a moment of anger about how they were wrongfully dismissed could entertain such thoughts. Having those thoughts or fantasies is, however, very different than acting on them. Virtually all of us have enough self-control and perspective to not succumb to those thoughts even if we were "screwed" and had no realistic legal recourse of correcting whatever injustice might have been done to us. Even if one had a valid basis for a lawsuit based on a claim of wrongful termination, it would take years for such a case to reach resolution, thus making it difficult to move on with one's life. Moreover, courts give a lot of discretion to residency directors and their decisions, thus placing the resident at an even greater disadvantage in any lawsuit filed. Unless something egregious or blatantly illegal was committed by the residency program and the resident can provide proof of such act, it would be difficult to prove one's case against subjective evaluations.

I personally know one resident who had the misfortune of being in a malignant program that pressured him to resign even though he was strong clinically and had the highest score on his inservice exam. This resident has not been able to find another residency position after his resignation despite reapplying several more times. This resident's life has been devastated by the vindictive act of this particular program director. He has incurred hundreds of thousands of dollars in debt to finance his medical education, and yet can not continue with his medical training, and his medical degree is worthless without having completed a residency program.

We need a system of checks and balances that would not give program directors essentially unlimited and unfettered power to ruin a resident's career. Someone needs to advocate for residents. I don't know what the optimal solution(s) for this problem would be but potential solutions would include an impartial and neutral review board that would review and rule on any termination decisions. Perhaps a residents' union would be another method to advocate for residents and close some of the enormous power differential between residents and program directors.

 

[dragonfly99]

I used to be against this (unionization of residents) but with my 20/20 "fellow hindsight" I think maybe it would be good. Nurses and other health care workers have unions, and they get treated better than interns and residents. If attendings and programs were all benign and wanted to train us (like my current program director and pretty much all attendings at my current program) we would not need a union. But program directors are human beings and prone to the same foibles as all other human beings. Programs and hospitals have their own interests, mostly based on money and/or prestige.

The problem with residents' unions is that current ones are ineffective. I know residents who work at unionized hospitals and they aren't treated nearly as well as I am at my current hospital. You can't squeeze blood out of a turnip, and many of these big city hospitals that are unionized just don't have much money or other resources to expend on residents and interns. A union would have to have a lot of power to be able to put pressure on a program director and/or hospital. What are we going to do, have resident walkouts, etc.? I think it would be unethical because we have to take care of our patients.

One's best bet as a resident is to find a program where you "fit it" well, work hard, and keep your head down.

I do know one person who resigned under threat of termination and extracted some sort of deal from the residency where they'd give him "x" months of credits for certain intern year rotations, and he agreed to leave and not sue, etc. I don't know in particular what the deal was, but I know that he got it in writing from them. And he I think got a letter of evaluation written by the PD, which I guess just stated which rotations he completed. I doubt it was a ringing endorsement. You're not going to get one from a PD in this situation. But he did manage to get another spot in a different specialty. He did have the financial resources to get an attorney. He also was a US grad with high USMLE scores, a scholarship to med school, good in service exam scores, etc.

 

[1892]

Hello I am in such a mess I started a residency in july and have now been asked to resign as They say I am not progressing at the same speed as the other residents, which I must say are all AMGs. I am from AUC. I was put on remediation for 6 weeks which I felt was never fair. They had thier minds made up from the beginning.there were nver any concrete guidelines for me to improve. I would ask and they woul give vague examples of what needed to improve.They throughout kept going back to when i has first started and my speed on the computer system which there are 2 different ones .
My question is should I resign or let them fire me. I have 2 children and a wife and if I resign I will not get any unemployment and my loans will come due. I can put them in deferment if I get fired. Also I read that if I resign the program gets to keep the 140,000 they got for me and if they fire me they have to give it back is this true. They are trying to blackmail me by saying if I resign they will then see how they can help me and if they have to fire me It could be worse. The Director is more likely to giv me a good review if another program calls about me if I resign, not so if they have to fire me. I am so lost and don't know who to talk with to get advice or counsel. Any help Thanks

Me too. I am an AMG, with high USMLE's and great letters of rec. I matched in a competitive field. I worked hard, and like you was put on academic probation. I was absolutely put on the sh*tlist. I acknowledge I fell behind my peers. It was a combo of the lack of staff, and for unlucky reasons, I did not get all the "basic" or core rotations until right before being expected to take call. I tried hard to persevere, but my learning and self esteem crashed after enduring the "stink eye" day in and day out.

Once placed on academic probation, it seemed the Chair had made his mind up. Despite showing dramatic improvement in the last few months, those evals where not even considered when the academic panel made their decision. I was offered the resign or get fired option. I chose resign.
Resigning sounds better, but my career feels equally screwed. I will likely not even be able to get a general med. license in my beloved home state because of this. The lawyer said "I could get a license in another state, or maybe get a physician in training license". Both depressing options.

I have stopped trying to find a position after 7 months. Resigning is a sucky option, too. I say, if you think you can learn at your program, try to fight it. I left because there was just no way I could learn under those hostile circumstances. If you attempt to stay, it may seriously hurt your marriage. It ruined my relationship, bc I became so depersonalized thru all this.

Anyone else who has hope or insight for me as well, please offer!

 

[J-Rad]

Anyone else who has hope or insight for me as well, please offer!

Can you share at what time your training was cut short, i.e. prior to completion of a PGY1 or after? I think honestly some deep thought upon what less competitive fields you may enjoy would be your starting point. The PGY1 question relates to at what point would you be (re) applying, i.e. for a new (fresh) PGY1, a PGY1 with some credit for previous completed PGY1 work (possibly affecting completion time of your new residency), or PGY2 in a residency that typically starts at that point. Psychiatry and PM&R are often spoken of as residencies that (can) begin at PGY2 that may be good options for someone in your position. There is also preventive medicine and occupational medicine, two often overlooked fields. FM is often less competitive, but there is only so much credit you can get for previous training and you would start as PGY1 as far as I (inexpertly) know. While you are meditating on these thoughts, I would also put some thought into what internal barriers you had to keeping up with your peers (obviously a toxic environment took its effect, but that isn't something you have control over. But you do have control over your response to those environments). Good luck to you.

 

[3dtp]

. . .
Resigning sounds better, but my career feels equally screwed. I will likely not even be able to get a general med. license in my beloved home state because of this. The lawyer said "I could get a license in another state, or maybe get a physician in training license". Both depressing options.

I have stopped trying to find a position after 7 months. Resigning is a sucky option, too. I say, if you think you can learn at your program, try to fight it. I left because there was just no way I could learn under those hostile circumstances. If you attempt to stay, it may seriously hurt your marriage. It ruined my relationship, bc I became so depersonalized thru all this.

Anyone else who has hope or insight for me as well, please offer!

(emphasis mine).

Once outside, looking in, the whole situation changes. The NRMP, which I regard as anti-competitive and likely would have been found to be in violation of the Sherman Act had not a Senator with vested interest in HCA hospitals added a rider to an unrelated budget act, is there to support programs.

Above someone stated that the match contract is binding upon programs and residents. This is true, but the NRMP does not equally enforce its violations sanctions against programs. Despite a determination that there was a preponderance of the evidence that an institution had committed an NRMP contract violation by (the arbitration panel) the NRMP ignored this and refused to enforce its contract against the program and institution. I had the TY PD slander me, and my PGY2 program violated the match based on that slander. The situation was settled and I did get my position, but it was 2 years late. Fortunately I had other skills and financial resources, and a damn fine attorney.

As for the Wang situation, that is tragic. The PD at my TY institution screwed similarly a senior categorical resident who nearly did something similar, but for the fact that I was attuned to this resident at the time, and knew there was a serious problem, probably would have happened.

Fortunately, in no small part due to the excellent training in a psychiatry rotation and an exceptional attending psychiatrist at that same institution that tried to screw me, I noted the s/s of major depression, intervened, and I am now a somewhat reluctant gun owner and no one was hurt, likely saving the lives of three people. This is a very real problem and a potentially devastating psychological response. It is also not a new problem. A similar incident took place outside University Hospital cafeteria at Univ. Michigan in the mid 1980s, resulting in two deaths and a life imprisonment without parole.

That former resident took 2+ years to find another position, with my and other attendings help and counseling and is doing well in private practice. Very well in fact.

As for getting back in once you are out, it does depend on whether you made the first full PGY1 year or not. If you did, you do have a better chance. You have been fire tested. If not, you have a higher mountain to climb. You cannot go through the NRMP, for it won't help you and many PDs are looking for reasons to DNR the hundreds of ERAS papers.

When I was "between" jobs, I looked at a couple of programs, secure in the knowledge that I was to matriculate into my chosen specialty residency, albeit delayed.

At the interview for one program, I realized it was a crosslisted dual specialty program with zero interest in GME, and 100% interest in a warm body to take Q2/Q3 call. As I sat in a sea of FMGs during the interview and was offered the position, I realized that I could be jumping from a frying pan into a very hot fire. I chose to step aside. The other was not much better. Be careful. The third was a fantastic program and a good experience until I matriculated into my chosen profession. I had great sadness leaving that program for my main interest and to this day look back fondly on that program.

If you are truly interested in clinical medicine, then 7 months is not adequate time. Going through the NRMP is not a good option. You, and those of you who are in this situation must move outside the box, get off the train and travel the back roads. My mentee followed this advice, and by personally visiting program, discussing this with them, ultimately he did find a PD who was willing to give him a chance outside the NRMP on a position that was created out of cycle. It takes a lot of luck, a lot of perspiration, some trust, a willingness to be an aggressive salesman of the hardest commodity there is to sell: yourself, especially after a bruising experience, such as yours.

If you truly want back in, be prepared for many rejections, because, although luck is a factor, you can make your own luck. Go back to your medical school dean, discuss the situation as frankly and as candidly as you can with him/her. You will have to travel on your own nickel. My friend mapped out a path, called for appointments to discuss the programs he was interested in trying to get into, drove and camped to save cash, worked odd jobs to pay bills, and essentially became a nomad for about 2 years before he finally hit on this now successfully completed program. Each path back may be somewhat different.

You have the advantage of good board scores. Go back to that institution and ask those whom you have had a good and successful working relationship for good letters of reference. Ask them if they can write a good one. If they can't ask them for a candid discussion of why not and what they think you can do to remedy where you fall short. This can be a very beneficial exercise, as you will clearly know what others are thinking, how you are perceived and will aid you in two things: showing insight to potential future PDs and disarming disingenuous comments.

I never sign liability waivers for letters of reference. If an institution or credentialing office insists, I amend the waiver to include the words, "provided such is provided in good faith." I do not believe they promote candor: if a potential letter writer cannot be candid to my face, then what promise do I have that they will be honest behind my back?

Sorry for the missive. There's a lot to this dirty business. Wish you well.

 

[3dtp]

I used to be against this (unionization of residents) but with my 20/20 "fellow hindsight" I think maybe it would be good. Nurses and other health care workers have unions, and they get treated better than interns and residents. If attendings and programs were all benign and wanted to train us (like my current program director and pretty much all attendings at my current program) we would not need a union. But program directors are human beings and prone to the same foibles as all other human beings. Programs and hospitals have their own interests, mostly based on money and/or prestige.

Don't forget arrogance.

The problem with residents' unions is that current ones are ineffective. I know residents who work at unionized hospitals and they aren't treated nearly as well as I am at my current hospital. You can't squeeze blood out of a turnip, and many of these big city hospitals that are unionized just don't have much money or other resources to expend on residents and interns. A union would have to have a lot of power to be able to put pressure on a program director and/or hospital. What are we going to do, have resident walkouts, etc.? I think it would be unethical because we have to take care of our patients.

In the days prior to EMR/automated billing platforms, a "resident" strike in Ann Arbor in the late 20th century worked because residents threw billing sheets in the trash for about 2 weeks. It worked then, but sigh, it probably won't work now.

One's best bet as a resident is to find a program where you "fit it" well, work hard, and keep your head down.

Excellent advice. Question is: how to bell that cat? Not all programs are what they seem.

I do know one person who resigned under threat of termination and extracted some sort of deal from the residency where they'd give him "x" months of credits for certain intern year rotations, and he agreed to leave and not sue, etc. I don't know in particular what the deal was, but I know that he got it in writing from them. And he I think got a letter of evaluation written by the PD, which I guess just stated which rotations he completed. I doubt it was a ringing endorsement. You're not going to get one from a PD in this situation. But he did manage to get another spot in a different specialty. He did have the financial resources to get an attorney. He also was a US grad with high USMLE scores, a scholarship to med school, good in service exam scores, etc.

Here we disagree. Programs should give credit where rotations are successfully completed. A threat to fail to give credit or giving credit where none is earned is dishonest. When I was offered a choice: resign or be fired, (I did neither), the PD posed it to me thus:

• If you resign, we will help you find another position, give you full credit for 7 months served.
• If you refused to resign, we will fire you effective immediately for "unprofessional behavior," give you no credit and you'll never work in medicine again.

I did not resign and was not fired. Despite this, the PD still did everything in his power to destroy me. That PD is no longer with that institution, and the GME director was removed following an ACGME investigation. This was a serious situation, wherein the PD and the GME director were clearly and unequivocally wrong, I had support of very powerful allies in that hospital and was able to pull out of a dangerous situation.

 

[NotAProgDirector]

There is no question that it's a complicated, messy situation.

Program Directors like myself have a duty to oversee the training of residents. That includes remediating those who don't meet performance criteria, and occasionally terminating those whose performance is unacceptable. The problem is that there really isn't any "check and balance" on a PD's decision. The DIO/GME director should perform this role, but is clearly not an "independent" arbitrator in many training systems.

Equally, you can understand why PD's would be wary of taking residents who have resigned/been terminated from other programs. The story always is "I was terminated unfairly, they didn't agree that I had improved, they had it out for me, etc". When evaluating this situation, it's "he said / she said" and often the easiest/safest thing to do is to move on to another applicant. Also, once I take someone I'm usually committing to a long term training commitment. If I have an off cycle opening, I'd much rather take someone who will fill the slot for the next few years, rather than someone whom I will evaluate for a few months and then decide what to do next.

The "resign and we help, or be fired and we screw you" option is completely unfair, illegal and ridiculous.

So, what we need is:

1. An independent way for termination decisions to be reviewed, one that both residents and PD's can agree is fair and balanced.
2. A fair way of summarizing problems that a resident had in a program (if terminated), so that other programs can review it
3. Some fair/objective way to actually evaluate resident performance.

Unfortunately, #3 is not possible. There is no objective way to evaluate resident performance -- it's all subjective. First, any objective system has a cutoff. On the USMLE, it's the minimum pass score. For Step 1, I believe it's currently 185. Get a 185 and you pass. Get a 184 and you fail. Do you really think there is any difference between the knowledgebase of a student who gets a 185 vs a 184? That's insane -- the statistical accuracy of the test is less than that. Hence, all objective measures are limited in that they need to have some arbitrary cutoff for competence that isn't realistic.

Plus, there's no way to objectively measure professionalism.

One of the biggest challenges in measuring resident performance is that it fluctuates. Residents whose performance is unacceptable 100% of the time are "easy" to terminate -- everyone agrees that they are completely incompetent. But that's rarely the case. Usually, a resident does a fine job 90%, 95%, or 99% of the time. No one is perfect 100% of the time, so we need to define some amount of "errors" that we consider normal or acceptable. And that's a huge challenge.

Also, it's important to realize that not all training programs are equal. Someone might come to my program and fail out, but go somewhere else and do fine. Perhaps the patient population / complexity is different. Perhaps the care delivery / call structures are different. Perhaps the support structrures are different. Who knows? But it happens all the time. Of course, no program wants to hear: This resident didn't do well in my program, but your program is much easier so I bet they'll be fine.

Regardless, I do think that some sort of appeals process would be helpful. The courts are a really poor choice for many reason -- they are not designed to handle this type of thing, and they take too long. An interesting idea floated here on SDN before would be some sort of nationally organized appeals process. Residents would create some sort of a board which would review all disciplinary issues. They would need to meet with PD's/faculty, and also with residents. They would review the evaluation file. They would help both parties come to an agreement about what would happen next. Basically, it's like mandated arbitration, but would need to specifically include people who are medically trained and have GME experience.

I think the whole issue of the NRMP is separate. Whether or not there is a match, the above issues remain a problem.

 

[3dtp]

There is no question that it's a complicated, messy situation.

Program Directors like myself have a duty to oversee the training of residents. That includes remediating those who don't meet performance criteria, and occasionally terminating those whose performance is unacceptable. The problem is that there really isn't any "check and balance" on a PD's decision. The DIO/GME director should perform this role, but is clearly not an "independent" arbitrator in many training systems.

Equally, you can understand why PD's would be wary of taking residents who have resigned/been terminated from other programs. The story always is "I was terminated unfairly, they didn't agree that I had improved, they had it out for me, etc". When evaluating this situation, it's "he said / she said" and often the easiest/safest thing to do is to move on to another applicant. Also, once I take someone I'm usually committing to a long term training commitment. If I have an off cycle opening, I'd much rather take someone who will fill the slot for the next few years, rather than someone whom I will evaluate for a few months and then decide what to do next.

The "resign and we help, or be fired and we screw you" option is completely unfair, illegal and ridiculous.

So, what we need is:

1. An independent way for termination decisions to be reviewed, one that both residents and PD's can agree is fair and balanced.
2. A fair way of summarizing problems that a resident had in a program (if terminated), so that other programs can review it
3. Some fair/objective way to actually evaluate resident performance.

Unfortunately, #3 is not possible. There is no objective way to evaluate resident performance -- it's all subjective. First, any objective system has a cutoff. On the USMLE, it's the minimum pass score. For Step 1, I believe it's currently 185. Get a 185 and you pass. Get a 184 and you fail. Do you really think there is any difference between the knowledgebase of a student who gets a 185 vs a 184? That's insane -- the statistical accuracy of the test is less than that. Hence, all objective measures are limited in that they need to have some arbitrary cutoff for competence that isn't realistic.

Plus, there's no way to objectively measure professionalism.

One of the biggest challenges in measuring resident performance is that it fluctuates. Residents whose performance is unacceptable 100% of the time are "easy" to terminate -- everyone agrees that they are completely incompetent. But that's rarely the case. Usually, a resident does a fine job 90%, 95%, or 99% of the time. No one is perfect 100% of the time, so we need to define some amount of "errors" that we consider normal or acceptable. And that's a huge challenge.

Also, it's important to realize that not all training programs are equal. Someone might come to my program and fail out, but go somewhere else and do fine. Perhaps the patient population / complexity is different. Perhaps the care delivery / call structures are different. Perhaps the support structrures are different. Who knows? But it happens all the time. Of course, no program wants to hear: This resident didn't do well in my program, but your program is much easier so I bet they'll be fine.

Regardless, I do think that some sort of appeals process would be helpful. The courts are a really poor choice for many reason -- they are not designed to handle this type of thing, and they take too long. An interesting idea floated here on SDN before would be some sort of nationally organized appeals process. Residents would create some sort of a board which would review all disciplinary issues. They would need to meet with PD's/faculty, and also with residents. They would review the evaluation file. They would help both parties come to an agreement about what would happen next. Basically, it's like mandated arbitration, but would need to specifically include people who are medically trained and have GME experience.

I think the whole issue of the NRMP is separate. Whether or not there is a match, the above issues remain a problem.

These are all excellent thoughts and I am in complete agreement. And therein lies the quandary. The meat of the matter is there is no clear independent review of what clearly has a significant "subjective" component. If the ramifications of a decision were not so far reaching, this would probably be a non-issue. e.g. "I got fired, these are the reasons, I am looking for a new position." But there are far reaching implications.

When I was looking to repair the damage done to me, after I had assured myself that my residency position was going to be honored, I had several PDs practically demand I file formal complaints against the program, one directly stating, "you must do something about this. PDs like x make us all look bad." There is indeed truth in this statement, and as the ACGME subsquently determined, there is a need from time to time to clean house.

I like your idea of an independent review process for evaluating resident terminations. I am certain that some are definitely warranted, but I suspect that fewer unwarranted terminations would take place if there was assurance of an outside, independent of the institution review.

I am told there are only about 800 or so residents terminated per year, it seems to me that an independent appeals panel, perhaps staffed by volunteers to hear these cases might be possible. This would be less adversarial than the courts and probably more fair. The courts since Schulman v. Washington Medical Center have been eager to dodge these cases, if they can.

How do we make something like this happen?

As for the NRMP, it is the crux of the problem, in my opinion. In a more laissez faire environment, it is more likely, again in my opinion that these situations would not develop or if they did, the end of the locked in for four or more years behavior would help both sides realize it is in the best of medicine to work to resolve their differences or allow more standardized and easier transfers to better suited programs.

I'd be interested in working with you to help get something like this started. Perhaps, initially on a completely voluntary basis to see if it changes outcomes or minds. And I'll back it with my own purse.

Regards.

 

[NotAProgDirector]

I like your idea of an independent review process for evaluating resident terminations. I am certain that some are definitely warranted, but I suspect that fewer unwarranted terminations would take place if there was assurance of an outside, independent of the institution review.

I am told there are only about 800 or so residents terminated per year, it seems to me that an independent appeals panel, perhaps staffed by volunteers to hear these cases might be possible. This would be less adversarial than the courts and probably more fair. The courts since Schulman v. Washington Medical Center have been eager to dodge these cases, if they can.

How do we make something like this happen?

It's going to be really, really hard to make something like this happen.

Any independent board would need to be equally acceptable to both programs and residents. How you'd build such a committee and keep it fair and balanced is unclear. You'd probably want both PD's and residents on such a committee, and any resident time is going to be very difficult to schedule. Alternatively, you could try to pick "gold star" PD's that you think would be fair, but this is going to be a time consuming, emotionally draining process and I expect that few would want to.

800 residents per year -- let's assume that number. Reviewing each case has to take at least 1 week -- between travel time, review of records, etc. That would mean at least 16 different groups working full time. Or, if you think each group could work twice as fast, that's still 8 groups. No way this is going to be volunteer. And it's going to be quite expensive.

So, if you really wanted to do this, I'd focus on a single specialty. Perhaps IM, or FM, or Peds might be a good choice. You'd need to get buy in from PD's and the RRC. This is going to be really, really hard.

The other way that I could see to do it would be to approach CIR. They could build something like this into their union contracts. Because it would be part of the contract, programs would have to honor it. Honestly, that seems to be the most realistic way.

As for the NRMP, it is the crux of the problem, in my opinion. In a more laissez faire environment, it is more likely, again in my opinion that these situations would not develop or if they did, the end of the locked in for four or more years behavior would help both sides realize it is in the best of medicine to work to resolve their differences or allow more standardized and easier transfers to better suited programs.

I disagree. The "problem" isn't the NRMP IMHO. If someone gets terminated from a residency program, finding a new spot outside the match (i.e. a PGY-2 off cycle spot) is just as difficult. Removing the NRMP doesn't solve any of these problems -- all PGY-1 positions start at the same time, and PD's will be wary of taking anyone terminated with "questionable circumstances".

I'd be interested in working with you to help get something like this started. Perhaps, initially on a completely voluntary basis to see if it changes outcomes or minds. And I'll back it with my own purse.

This is a huge undertaking. I'm not certain its what I want to put my energy into, nor am I in a position to do so. As above, you'd probably either need a top-down approach (i.e. the ACGME/RRC making this a rule) or a bottom up approach (having individual programs agree to do this, likely with CIR backing).

 

[MD forever]

Regardless, I do think that some sort of appeals process would be helpful.

What do you say for those programs that, after terminating a resident, they do not follow the due process, appeals and hearings, which is written in their hospital policy, yet not honored by the same, [residency program / GME]. ACGME know about it, Nothing happen! All this under direct supervision of the hospital lawyer.

I had friend of mine who had the above situation. She wanted to move forward with her career but.....beat:

 

[dragonfly99]

In spite of the supposed appeals processes, etc. it's my strong impression that at most programs if the program director wants you out, you're just out. Usually the other faculty and dept. chair will just go along with them. And it's a total he said/she said situation, like APD says. The resident will always feel it was "unfair" and the program director will always stick to the opinion that the resident was incompetent and/or "unprofessional". Both those defects are in the eye of the beholder ("professionalism" more so, IMHO).

 

[3dtp]

In spite of the supposed appeals processes, etc. it's my strong impression that at most programs if the program director wants you out, you're just out. Usually the other faculty and dept. chair will just go along with them. And it's a total he said/she said situation, like APD says. The resident will always feel it was "unfair" and the program director will always stick to the opinion that the resident was incompetent and/or "unprofessional". Both those defects are in the eye of the beholder ("professionalism" more so, IMHO).

This pretty much sums it up. These policies and processes are put in place either because the acgme requires it or to provide face to what the institution is going to do. It is there to protect the institution and not the individual.

APD correct about one thing: setting up an independent review board is hard work and would be expensive. That can be overcome. What can't be overcome is those that have power over others will rarely voluntarily relinquish that power.