thanks everyone!
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tough predicament
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read your contract, contact the resident union if you have one and call a lawyer. No need to bother with anyone's advice on this forum including me.
Theyhave to give you ongoing feedback and ample time for remediation prior to failing you. thats their job.
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agree as quoted above. also, you should obtain copies of all evaluations to date and obviously should have copies of in-service exam scores. we often hear about things that sound very unfair on these forums. However, if you are otherwise stellar except for some 5-6wk rotation, it should be obvious to objective observers by reading your evaluations and in-service exam results to date.... If those are consistent with what your PD is reporting for this 5-6wk rotation, then you have failed to heed the warnings.
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If it's just one month, then I would just go ahead and do it.
But do read your resident handbook on non-renewals, suspensions, and academic credit. Know the policies and your substantive protections if any that are granted in your handbook. Do not rely on the PD. If he turns on you, then this knowledge will come in handy. Do not rely on the residents union. Their law services do not include fighting an adverse decision by the program. But do see if they can refer you to an attorney interested in pursuing these types of cases.
Repeating a rotation for failing it is not unfair. What often happens is that the program will try to get you to do many more months than just that one rotation. If they think you will resist, then they could start influencing your other attendings or assign you attendings that do not want you to succeed to make sure you do not do well enough to justify whatever sentence they think you deserve. Don't blame the chiefs. Often they are obeying orders from higher up.
This is a dangerous game that programs play. They do not have judicial experience to start handing out sentences that may have nothing to do with real clinical competence. This scenario is of course a problem with unfettered deference. As more residents learn of what happens, more of them will decide to litigate.
Those attendings that participate in such conduct should be aware that they put themselves in a liability position for a tort should the resident decides to sue. Torts include the possibility of punitive damages if a gang-up situation could be reasonably inferred. Even in conservative circuits, ganging up against an employee increases the chances of personal liability as well as any vicarious liability on the part of the hospital, medical school, or healthcare system. The more titled personel involved, the more vicarious liability gets implicated. The more people involved, the more difficult it is to hide tortious conduct under cross examination. Litigation can become ugly very fast with attacks on the credibility of witnesses on both sides. What starts off as something petty can become a nightmare for most involved. Punitive damages means protecting assets and bankruptcy for most attendings, because malpractice insurance does not cover tortious conduct that does not directly involve patient care. It will be expensive to defend against a spirited labor attorney who sees deep pockets everywhere.
I think that in the future, programs will adopt both procedural and substantive protections for residents to prevent tortious conduct from rogue PDs or attendings from causing legal harm. Not because they want to, but because it makes financial sense. It's cheaper to spend a few thousand dollars per resident to make sure that an adverse decision is correct, than to pay for an attorney to prosecute a motion for summary judgment, or even worse, to face the uncertainty of a jury.
This could be the start of something. Watch out for yourself. For now, avoid trouble as best you can.
But do read your resident handbook on non-renewals, suspensions, and academic credit. Know the policies and your substantive protections if any that are granted in your handbook. Do not rely on the PD. If he turns on you, then this knowledge will come in handy. Do not rely on the residents union. Their law services do not include fighting an adverse decision by the program. But do see if they can refer you to an attorney interested in pursuing these types of cases.
Repeating a rotation for failing it is not unfair. What often happens is that the program will try to get you to do many more months than just that one rotation. If they think you will resist, then they could start influencing your other attendings or assign you attendings that do not want you to succeed to make sure you do not do well enough to justify whatever sentence they think you deserve. Don't blame the chiefs. Often they are obeying orders from higher up.
This is a dangerous game that programs play. They do not have judicial experience to start handing out sentences that may have nothing to do with real clinical competence. This scenario is of course a problem with unfettered deference. As more residents learn of what happens, more of them will decide to litigate.
Those attendings that participate in such conduct should be aware that they put themselves in a liability position for a tort should the resident decides to sue. Torts include the possibility of punitive damages if a gang-up situation could be reasonably inferred. Even in conservative circuits, ganging up against an employee increases the chances of personal liability as well as any vicarious liability on the part of the hospital, medical school, or healthcare system. The more titled personel involved, the more vicarious liability gets implicated. The more people involved, the more difficult it is to hide tortious conduct under cross examination. Litigation can become ugly very fast with attacks on the credibility of witnesses on both sides. What starts off as something petty can become a nightmare for most involved. Punitive damages means protecting assets and bankruptcy for most attendings, because malpractice insurance does not cover tortious conduct that does not directly involve patient care. It will be expensive to defend against a spirited labor attorney who sees deep pockets everywhere.
I think that in the future, programs will adopt both procedural and substantive protections for residents to prevent tortious conduct from rogue PDs or attendings from causing legal harm. Not because they want to, but because it makes financial sense. It's cheaper to spend a few thousand dollars per resident to make sure that an adverse decision is correct, than to pay for an attorney to prosecute a motion for summary judgment, or even worse, to face the uncertainty of a jury.
This could be the start of something. Watch out for yourself. For now, avoid trouble as best you can.
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A lot of it turns on what your contract says. At many places, you get official feedback at the end of each rotation (often in the form of online evals) and at least quarterly by the PD. The rest of the feedback you get is more of a courtesy than a requirement. Every accredited rotation is going to have goals/requirements published and distributed to you, as it's an ACGME requirement, but it may be hidden in a handbook you got at orientation and lost, which won't be deemed the program's fault. If you "fail" something, the program is required to tell you and give you a chance to remediate before throwing you out, not graduating you, not renewing your contract, etc. Allowing you to remedy your shortcoming in a rotation by working some additional time is probably not going to be deemed so egregious that you will have the ability to go up the food chain for justice. In many cases this is going to be deemed quite reasonable.
It also depends a lot on what your shortcomings actually were. If you did something that would cause the typical PD to throw you out, and the program instead said, spend an extra couple of months to prove this was an aberration, then you probably should be thanking your program, not looking to sue them. If instead, this is simply your programs way to hang on to residents illegally, then you probably have some claim, but this is something very very hard to prove. Also, going through the ACGME, or legal system will take a lot of time, and probably result in you not finishing your residency on time, even if you prevail. So it might be a Pyrrhic victory at best. Wont help you, maybe will help the next guy. If we are talking a month or two, or if the shortcoming was a real one, I probably would suck it up and finish out the term.
thanks Roofie-- your post is really enlightening! this whole thing has been so stressful. I have never heard of a PD trying to sabotage the resident's career. but what do I know as a naive resident. I guess I'll do 1-2 months of make up if that's the decision. however, if the PD tries to keep me longer and fail me on other rotations, I may have to go the legal route. although, i am really worried about going that route as a young resident on the verge of finishing residency. my other option is to quit this program and find another spot somewhere for PGY3.....it may be tough to get a 3rd year spot elsewhere. any thoughts?
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It's going to be hard to fight this. I wonder what happened to cause you to fail and outpatient rotation. It's normally the ICU or wards that gets people into trouble. Did you not show up at all the clinics on time or something? If it's just a matter of repeating a month or two, probably better to just suck it up and eat the extra time, as long as they'll let you finish. 1 or 2 months in the grand scheme of things doesn't matter. It would/will matter if you were supposed to start fellowship next summer or something. It may hurt you a bit when it comes to licensing, etc. because they usually ask if you were ever on probation, had to remediate something, etc. If you want, you can ask your PD if you could repeat the 1 month as part of your next 6 months, but he probably doesn't want to let you or he would have offered. That would necessitate dropping you from some other rotation, and perhaps they need you to work the wards, etc. or you still have ACGME-required months of other things (ICU, wards, etc.) that you need to do.
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I believe you are required to spend the last two years of residency in the same place, so you'd be looking for a PGY-2 position elsewhwere, not a PGY-3.
I was shocked to learn that I failed clinic too-- who ever fails clinic right? so far I have been passing wards and ICU but i am a bit paranoid that they can fail me on those rotations and justify making me stay longer.
i showed up to clinic on time, saw my patients, carried my required responsibilities, was professional and had no issues with staff. they failed me on the grounds that I was not demonstrating management plans for the cases I presented to attendings ( i had clinic first 2 months of 3rd yr and my management was no different than end of 2nd year). I have no problem with negative feedback if it's intended me for grow and learn as a resident to be independent. but to not get any word of feedback during those weeks of clinic and suddenly find out month later that I failing that rotation from the PD and that I am not graduating on time was very hurtful/ felt like a bomb was dropped on me.
I already asked the PD if i could make it during elective time in the next 6 months and the answer was a resounding No. the PD is hell bent to making me stay longer. now I don't mind repeating 1-2 months of out pt clinic but if they keep longer and prevent me from taking boards and sabotage me that's just not right. i didn't harm any patients. although my notes in the charts are evidence of my thought process and management apparently it boils down to waht attendings think.
i thought you could switch residency as pgy3...saw some IM pgy3 open spots a while ago. please clarify.
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I thought that aPD had discussed this issue before but I cannot find a link on the ACGME website regarding such a requirement. I will table the discussion on it until he weighs in.
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I feel for ya brother. Just out of my naivete, do you feel confident? Do you feel like you do not need more time? I don't mean anything rude by this...
Keep your chin up. I don't think you should get emotional and quit...just get through it and then do this:
http://www.youtube.com/watch?v=Fp6olw9iaxE&feature=related
Fight the good fight! Good luck!
Keep your chin up. I don't think you should get emotional and quit...just get through it and then do this:
http://www.youtube.com/watch?v=Fp6olw9iaxE&feature=related
Fight the good fight! Good luck!
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IIRC, it's specialty-board specific. I know it's the rule in FM but I don't think it's the case in IM and I have no idea about Peds.
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Its also the case for Surgery - thought I remembered aPD talking about it in the case of IM, but perhaps he was referring to FM.
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Agreed. It's a rule in FM and GS, but not IM. Still, as the OP points out, it's not easy to simply get a PGY-3 in IM either.
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Just to add a couple points.
This is an overall troubling problem you face. Some state licensing boards will actually ask specifically about training failures and/or remediation... But, I would be cautious on characterizing the PD as hell bent and otherwise punitive. He/she may be such.
However, as to doing "extra" time, it is not in general unreasonable to deny your use of elective time. For discussion sake, let us say you did very subpar and your PD is MotherT. Still, you FAILED. That means a 4-6 week block of training was inadequate, aka not completed. That time, in order to be fully residency trained must be redone.... in addition to completing your remaining clinical requirements. Thus, you can not replace a remaining rotation with the remediation time.... you would still end up with a 4-6 week shortage of training time. The only way you could avoid this would be to use vacation, aka non-training time to make up your lost block. It would be the same as if a female resident took off (non-vacation) 6 weeks post-partum. She could not make it up by filling/replacing her electives with the missing 6 weeks. The time is time and needs to be completed.
As for changing programs, that will be very hard. As noted above, you failed that rotation. You will need your attendings and PD to vouch to the accepting program. Then, they would likely still expect you to complete a full training program to graduate. That is, you would get credit for what you completed at your current program and have to complete what remains at your new program. What you failed would not be considered completed work.
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I find it interesting that many times residents have no idea that they are performing poorly. They are surprised when action is taken to remediate them.
Your program may have waited too long to remediate you. Programs sometimes pass residents through and receive an epiphany during the residents' last year. " This guy/gal isn't ready to leave."
It is my experience that programs are often unwilling to take action when they should do so.
Programs generally do not have the time to single out a particular resident and set out to ruin a career. I am not saying that this may not happen but is usually not the case.
Many residents who are placed on probation/ remediated seem to be blind sided by this.They never saw it coming. This may merely be a function of a lack of self-awareness.
The best defense against being blind sided is to seek feed back often. If you think that you are not performing well do not bury your head in the sand. Be proactive and contact your advisor or someone else whom you can trust.
I once came across a poor performing specialist. He had been sited by his state board and had his priviledges revoked at various hospitals. He wanted me to refer patients to him but I felt that it was unethical for me to do so.Attempts were made to remediate this physician while he was still in medical school. His family hired a lawyer and had the dogs pulled off their son. I have no idea how this guy feeds and clothes himself, today.
To the Op, do not leave your program. Work with your program. Your PD will be happy to see that you are taking him seriously and your'e making an effort to improve your performance. Seek constructive criticism and work to improve your practice of medicine.
Cambie
Your program may have waited too long to remediate you. Programs sometimes pass residents through and receive an epiphany during the residents' last year. " This guy/gal isn't ready to leave."
It is my experience that programs are often unwilling to take action when they should do so.
Programs generally do not have the time to single out a particular resident and set out to ruin a career. I am not saying that this may not happen but is usually not the case.
Many residents who are placed on probation/ remediated seem to be blind sided by this.They never saw it coming. This may merely be a function of a lack of self-awareness.
The best defense against being blind sided is to seek feed back often. If you think that you are not performing well do not bury your head in the sand. Be proactive and contact your advisor or someone else whom you can trust.
I once came across a poor performing specialist. He had been sited by his state board and had his priviledges revoked at various hospitals. He wanted me to refer patients to him but I felt that it was unethical for me to do so.Attempts were made to remediate this physician while he was still in medical school. His family hired a lawyer and had the dogs pulled off their son. I have no idea how this guy feeds and clothes himself, today.
To the Op, do not leave your program. Work with your program. Your PD will be happy to see that you are taking him seriously and your'e making an effort to improve your performance. Seek constructive criticism and work to improve your practice of medicine.
Cambie
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I agree. Too many attendings are afraid or unwilling to be the "bad guy/gal" for any number of reasons. Many try to follow the "if you don't have anything good to say, don't say anything at all..." while others are always trying to "focus on the positive". Whatever the case, it can mean a significant training failure with a prolonged loss of time and opportunities.
I have found it very difficult on occasion to counsel and evaluate residents. Their feelings can get hurt. But, that is not really the difficult thing. The harder issue is when they pull out "glowing evals" from other attendings to counter the adverse counseling. When you read between the lines on these "glowing evals", very little is said about the actual clinical abilities/performance.
So, I am stuck with a resident that attendings have avoided honest evaluation (i.e. "he/she is really nice.... patients really like him/her.... gets along with others well....".). What is missing in the eval is the glaring belief AND complete assessment, "he/she is really nice, patients really like him/her, gets along with others well, but.... I wouldn't let him/her operate on my neighbors dog!". These reseidents (not directed at the OP) often have poor in-service performance combined with highly developed social skills that allow them to recruit resident colleagues to help/cover/recover for them. It's worse when they also recruit the "support" of the nurses and ancillary staff....
Out of curiosity: let say it was the way around. The resident was not a nice person (what ever that means) who had the compassion and back-up of the nurses and fellow residents, BUT he/she was the next Debakey in the OR. Would he still get a glowing eval from you or the other attendings? I believe that the so called nice persons will rise the letter of career faster than those who are actually excellent at the field.
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You have some typos and so, I am having a little difficult being sure I understand your final point/belief....
Patients first and foremost come to "you" with illness that requires competent medical skills. Unless you are a social worker or counselor, they didn't come to you primarily to talk about family recipes. I don't look for saints in the social aspect, I look for normal, balanced/stable individuals that are clinically competent. I find far too many residents these days that think being social butterflies and smooshers is in some way a short cut or worse, excuse to ignore clinical competence. Those "nice guy/gals" that clinically perform underpar are not going to suddenly make up all the lost training/learning opportunities later.
Bottom line, if you are socially inept, you will likely be sanctioned, disciplined, and/or loose your license along the way. If you are nice but clinically inept, your patients will be injured or worse. We expect healthcare providers, nurses, residents, attendings, etc.... to behave in a professional manner. We expect that coming in the door. That is a minimum standard. We expect residents to be clinically sound leaving stepping out of the door!
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Trouble is is that this is an uncommon scenario.
There are few "Debakeys/Camerons/Zollingers" etc.
There are few technically incompetent residents.
Most everyone falls into the middle ground. And while it is true that one should not assume that having wonderful social graces *replaces* technical skills and knowledge base, I hold that those who do have such skills will do better than the ******* with "great hands".
IMHO, there are few procedures which are so technically demanding/rare that they require a superstar surgeon.
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Which is where I greatly disagree with you. Yes, social interaction is crucial. But, I again believe good "socialization" necessary in being a functional adult should have already taken place well before you get to residency. A "success" in the medical field requires having the basics to begin with, i.e. be a normal adult human being AND good knowledge/skills.
Knowledge and skills are NOT of less importance. I find plenty of young residents that feel their good demeanor should be enough and/or compensate for their lack of clinical preparedness. As I said, I expect a normal, well balanced human being to begin with before orientation begins. But, that is a basic prereq on which we will build a competent physician by teaching clinical knowledge and skills.
I definately hear the arguments in both directions.... i.e. social butterfly that believes their social skills are more important then their failure to develop/demonstrate clinical proficiency and the residents that think they can be A@@ holes because they think they are the "next Debakey". Sorry, no dice. Be a regular human being and then learn to become a skilled physician.
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I went to OSU and heard all sort of Zollinger stories that just made you roll your eyes.
My fav was that when patients families would visit, he would have the housestaff removes all lines/tubes from the patients as able to make them more presentable
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I have always disagreed with the notion that a resident needs to be sociable with the people he works with to be a competent physician. Certainly he can't be an A**hole to patients.
I believe there is room in this profession for A**holes who believe they are the next Debackey. These guys are the ones who will more likely take on difficult cases, because they believe they are that good and they do not worry about their "stats" as much.
To be sure, being an A**hole will likely increase the chances of getting fired for pretextual reasons and is not good on average for a medical career. Physicians do not like referring their patients to A**holes. That's their legitimate choice.
However, the notion that attendings will purposely expose such a**holes to a heightened competency standard smacks of self-righteousness and is an abuse of what should be an objective evaluation. Many evaluators can't separate personal feelings from objective evaluations. What is made worse is that these evaluations may implicate the color of law in licensing issues or severely affect a physician's livelihood.
A**holes will have limited economic opportunities but they can still contribute to this profession. They can function as solo practitioners or find groups willing to tolerate their personal shortcoming given their other formidable strengths. Their wholesale persecution by the establishment smacks of injustice. This persecution is an example of liberal ideology embracing more totalitarian methods in effecting change. What ever happened to the notion of first do no harm?
If a program does not like a**holes, then it should better screen them prior to acceptance. Cutting a**holes off after they have made major commitments to the program wastes federal funds in getting enough technically competent physicians onto the marketplace and violates many basic legal theories that this profession can get away with due to unfettered deference.
There is a perception that there are a**holes in surgery. Many of them are really good. That's fine with me. If I need an operation, I could care less if the physician is nice to others. All I would care about is whether he is technically competent and could get me out alive without complications.
Quite frankly for an internist, I would prefer a Dr. House over someone personable and less competent.
I do not endorse being an a**hole to your colleagues, but I will work with a**holes regardless of my personal feelings. I do not think they should be persecuted in a training environment; however, they should be made aware of their shortcoming. They should be held accountable to the same technical standard as everyone else.
I believe there is room in this profession for A**holes who believe they are the next Debackey. These guys are the ones who will more likely take on difficult cases, because they believe they are that good and they do not worry about their "stats" as much.
To be sure, being an A**hole will likely increase the chances of getting fired for pretextual reasons and is not good on average for a medical career. Physicians do not like referring their patients to A**holes. That's their legitimate choice.
However, the notion that attendings will purposely expose such a**holes to a heightened competency standard smacks of self-righteousness and is an abuse of what should be an objective evaluation. Many evaluators can't separate personal feelings from objective evaluations. What is made worse is that these evaluations may implicate the color of law in licensing issues or severely affect a physician's livelihood.
A**holes will have limited economic opportunities but they can still contribute to this profession. They can function as solo practitioners or find groups willing to tolerate their personal shortcoming given their other formidable strengths. Their wholesale persecution by the establishment smacks of injustice. This persecution is an example of liberal ideology embracing more totalitarian methods in effecting change. What ever happened to the notion of first do no harm?
If a program does not like a**holes, then it should better screen them prior to acceptance. Cutting a**holes off after they have made major commitments to the program wastes federal funds in getting enough technically competent physicians onto the marketplace and violates many basic legal theories that this profession can get away with due to unfettered deference.
There is a perception that there are a**holes in surgery. Many of them are really good. That's fine with me. If I need an operation, I could care less if the physician is nice to others. All I would care about is whether he is technically competent and could get me out alive without complications.
Quite frankly for an internist, I would prefer a Dr. House over someone personable and less competent.
I do not endorse being an a**hole to your colleagues, but I will work with a**holes regardless of my personal feelings. I do not think they should be persecuted in a training environment; however, they should be made aware of their shortcoming. They should be held accountable to the same technical standard as everyone else.
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Surprising and suggests less medical understanding and even less awareness of DrHouse.... He is wrong more then he is right, he experiemnts more then practices good medicine and as in in all fiction a blaze of luck and light bulb shiny moment seems to save the day at the end....
Frankly, I want a physician that actually gets things right rather then runs every last test in the world, experiemnts on me, has unqualified individuals performing surgical procedures, and walks into OR's contaminating the field.... based on your interpretation, you clearly lack some basic awareness of real medicine and speak like a member of the lay population that doesn't know any better.
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LOL at Roofie's last post...I kind of agree.
Jack-A-Deli, that was a bit tongue in cheek, I think. And we all know that by a "Dr House" he meant someone brilliant but somewhat rude. I don't like House either (the show or the doc on the show) but it's for entertainment.
I think that there are too many residents who kiss up to the PD and other attendings and get by that way, and not enough who are independent thinkers. It's important to toe the line when necessary, and of course do what one's attending wants/follow orders as needed, but sometimes doing what is best for the patient requires a bit of disagreement, or at least thinking about what ELSE could be going on with the patient other than what has been assumed. Some attendings and PD's want people to go along by getting along, even if it means not going all out for the patient. I have a friend who I'm pretty sure saved a patient's life, but in the process ruffled a few feathers (respiratory therapist who didn't want to do a stat blood gas, nurses who didn't like taking orders from an assertive young physician in the heat of the moment when patient was bleeding to death, etc.). The person was rewarded by being sent somewhere to be "re-educated" in a group with professionals who had taken drugs, slept with their patients, etc. If the patient had died but no hospital staff had gotten ticked off, I seriously, seriously doubt there would have been any consequences at all. Something is wrong there.
Jack-A-Deli, that was a bit tongue in cheek, I think. And we all know that by a "Dr House" he meant someone brilliant but somewhat rude. I don't like House either (the show or the doc on the show) but it's for entertainment.
I think that there are too many residents who kiss up to the PD and other attendings and get by that way, and not enough who are independent thinkers. It's important to toe the line when necessary, and of course do what one's attending wants/follow orders as needed, but sometimes doing what is best for the patient requires a bit of disagreement, or at least thinking about what ELSE could be going on with the patient other than what has been assumed. Some attendings and PD's want people to go along by getting along, even if it means not going all out for the patient. I have a friend who I'm pretty sure saved a patient's life, but in the process ruffled a few feathers (respiratory therapist who didn't want to do a stat blood gas, nurses who didn't like taking orders from an assertive young physician in the heat of the moment when patient was bleeding to death, etc.). The person was rewarded by being sent somewhere to be "re-educated" in a group with professionals who had taken drugs, slept with their patients, etc. If the patient had died but no hospital staff had gotten ticked off, I seriously, seriously doubt there would have been any consequences at all. Something is wrong there.
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Physicians with poor people skills usually do not do well. A jerk with good technical skills is still a jerk. These people create toxic work environments. they lack emotional reserve so every little thing is a big annoyance for them.
They create an unuaually large power differential so other members of the team do not feel at liberty to speak up even if something is wrong and a bad outcome is about to occur. I have seen such idiots crash and burn in private practice. Those with poor people skills seem to do better in academics.
Malcolm Gladwell has a great book on human performance. IQ is important to a point. There is minimum IQ that one must have to become a physician. After that IQ has been reached the rest seems to depend on social skills, EQ if you will.
This is a great book. It was amazing to see what a guy with one of the highest IQs in the nation is doing for a living.
The days of the idiots who rise to the top are gone. Turds simply sink.
Cambie
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