Ugh, turnover, is this normal?

[Doctor Bagel]

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Unfortunately, this has been an ongoing problem in my program, and I'm wondering what rate of turnover is normal. It's a ridiculously demoralizing/depressing experience for a program.

 

[peppy]

What kind of circumstances are we talking about: Every year your program fires someone, or every year someone transfers to a different program? That makes a big difference IMO.
From what I've seen, it is not normal for programs to fire people on a regular basis. We haven't fired anybody in the time that I've been at my current residency. If this program is firing people every year, I think that suggests either a problem with their selection/screening process or the leadership has unrealistic expectations of residents.

 

[twright]

Once again, my program is facing losing another resident, and I just wanted to know how much turnover is in the remotely normal range for a program? 5%, 10%, 20%? Is there a point where it extends beyond bad luck and indicates something about your program? What I do know is that it's ridiculously demoralizing. And about remediation -- does it ever work? My current picture is that if you go the remediation stage, you're pretty much done for. Is that true elsewhere?

And for applicants, no, I won't share where I'm at (although it's not a huge secret). As I honestly have no idea how to conceptualize the turnover we've had, I can't say if it should or should not affect your decision to train at my program.

Ugh. Sorry to hear it. In my 4 years, we had 1 resident who quit for family-related reasons. Even though we were a large program, the departure was still pretty disruptive to everyone else.

Multiple departures certainly says something about the program. Could signal something about the work hours, or the extent to which the administration prioritizes service needs over education, or even just the ability of the program director to pick winners. But it certainly says something.

 

[DrAwsome]

Once again, my program is facing losing another resident, and I just wanted to know how much turnover is in the remotely normal range for a program? 5%, 10%, 20%? Is there a point where it extends beyond bad luck and indicates something about your program? What I do know is that it's ridiculously demoralizing. And about remediation -- does it ever work? My current picture is that if you go the remediation stage, you're pretty much done for. Is that true elsewhere?

And for applicants, no, I won't share where I'm at (although it's not a huge secret). As I honestly have no idea how to conceptualize the turnover we've had, I can't say if it should or should not affect your decision to train at my program.

Is the resident being fired or transferring? I think transferring is fairly common, but if the program continues to fire people, then I'd say it's the program's issue.

I hope you are not at Stanford. Before I made the specialty choice I made, I interviewed for psych at Stanford, and the people there were absolutely insane, and was told several people transferred out of the program. Had I gone into psych and matched there, I think I would have transferred out as well. If you are at another program and the faculty keep firing residents, then I'd say that's concerning.

 

[LimbicResponse]

Once again, my program is facing losing another resident, and I just wanted to know how much turnover is in the remotely normal range for a program? 5%, 10%, 20%? Is there a point where it extends beyond bad luck and indicates something about your program? What I do know is that it's ridiculously demoralizing. And about remediation -- does it ever work? My current picture is that if you go the remediation stage, you're pretty much done for. Is that true elsewhere?

And for applicants, no, I won't share where I'm at (although it's not a huge secret). As I honestly have no idea how to conceptualize the turnover we've had, I can't say if it should or should not affect your decision to train at my program.

I'm sorry to hear this, but as an applicant I can tell you that I would take this information very seriously and not consider ranking a program that keeps losing residents. Whether it is bad luck or truly a problem with the program, I don't want to be the one that figures it out.

 

[Doctor Bagel]

Ugh. Sorry to hear it. In my 4 years, we had 1 resident who quit for family-related reasons. Even though we were a large program, the departure was still pretty disruptive to everyone else.

Multiple departures certainly says something about the program. Could signal something about the work hours, or the extent to which the administration prioritizes service needs over education, or even just the ability of the program director to pick winners. But it certainly says something.

Hmm, so maybe not typical. Unfortunately in these situations, the residents only hear part of the story due to confidentiality restrictions and whatnot, so it's hard to know what to think or feel. Well, aside from just feeling incredibly sad.

 

[Doctor Bagel]

I'm sorry to hear this, but as an applicant I can tell you that I would take this information very seriously and not consider ranking a program that keeps losing residents. Whether it is bad luck or truly a problem with the program, I don't want to be the one that figures it out.

You know, as an applicant, I 100% felt the same way. In fact, I routinely asked programs about resident losses when interviewing (got this idea from SDN).

 

[TexasPhysician]

Losing multiple residents is a red flag in my book regardless of reason.

 

[NYCMS2]

I'm sorry to hear this, but as an applicant I can tell you that I would take this information very seriously and not consider ranking a program that keeps losing residents. Whether it is bad luck or truly a problem with the program, I don't want to be the one that figures it out.

I agree. On my pre interview / app list, officially another one bites the dust.

Now can anyone else reveal similar programs with this problem? Or can someone pvt msg a list to me? Because I have no intention of getting caught in this kind of a trap, whether it would happen to me or not - it seems extremely disruptive to the work load, and also very demoralizing to the residents in the program.

 

[OldPsychDoc]

I agree. On my pre interview / app list, officially another one bites the dust.

Now can anyone else reveal similar programs with this problem? Or can someone pvt msg a list to me? Because I have no intention of getting caught in this kind of a trap, whether it would happen to me or not - it seems extremely disruptive to the work load, and also very demoralizing to the residents in the program.

It's even more demoralizing to have a colleague who is either grossly incompetent, interpersonally ineffective, or just plain does want to be there.

The whole system--all these applications and interviews that you'll soon be complaining about--is our effort to prevent these disruptions. We have no crystal ball--and the Match can throw us a curve as well. Ultimately programs get what they get on March 18th--no take backs or do-overs.

I'm actually surprised it doesn't happen more often--medical training is usually ( in the US at least) a 12 year period in which young adults have put their lives on hold to chase a dream that they understand poorly. You start out as a pre-med with romantic notions of becoming a doctor and immerse yourselves in 6 years of studying and testing that is only marginally related to the realities of what it's actually like to practice. This is followed by 6 years of apprenticeship in which you're subjected to heirarchies populated with driven and dysfunctional people, all of whom have their own agendas--and teaching, training, and nurturing your career is of peripheral interest to most. Little attention is given to you and your needs, changing goals and tastes, and life events. You've never had a job where you had to show up every day at a set time for more than a month straight. Your 12 year isolation from the "real world" has left you with little understanding of how simple things like mortgages, retirement accounts, and marriages are worked out. Again, if you're still reading this and not calling your program director to resign, you're a survivor, a resilient one. This is real life. It happens. We wish it didn't. We don't set up the system to cause it. Yeah, a wave of departures can point to something systemically wrong with a program, but one a year shouldn't indicate anything other than that Life Happens, and Program Directors are neither prescient nor infallible.

 

[BobA]

It's not always a bad thing to lose residents - especially if it's the program firing the resident. Sometimes applicants look good on paper, but when they show up to work you see something else. Of course, programs should work with residents to build them up, but some people aren't able to raise their level of work despite extra help.

I think it can be a sign of integrity that a program will dismiss residents who cannot work up to their standards. This is especially true in psychiatry - where there are a lot of bad psychiatrists out there. We don't need any more.

 

[NYCMS2]

It's not always a bad thing to lose residents - especially if it's the program firing the resident. Sometimes applicants look good on paper, but when they show up to work you see something else. Of course, programs should work with residents to build them up, but some people aren't able to raise their level of work despite extra help.

I think it can be a sign of integrity that a program will dismiss residents who cannot work up to their standards. This is especially true in psychiatry - where there are a lot of bad psychiatrists out there. We don't need any more.

Yeah, but...Doctor Bagel's program is one of the best known in the country, not exactly a backwater that doesn't get a shot at mostly top candidates.

It may be a sign of integrity that a program occasionally has to fire someone, but when it is one or more residents a year, something else is going on, and I am not interested in personally finding out what the problem is.

 

[NYCMS2]

It's even more demoralizing to have a colleague who is either grossly incompetent, interpersonally ineffective, or just plain does want to be there.

How often does this happen at the top programs (you know, the 20 to 30 programs discussed here ad nauseum)?

Begs the question of how and why this happens, particularly on your first two points (incompetence and interpersonal problems).

I just want to know the programs where this happens regularly as opposed to occasionally. Can some of you folks in the know provide us with this information?

Many thanks to Doctor Bagel for his/her frank discussion of this matter that is more hidden than it should be.

 

[Doctor Bagel]

How often does this happen at the top programs (you know, the 20 to 30 programs discussed here ad nauseum)?

.

Honestly, this is my question as well. I agree it's a tough situation all around, and I hope program directors aren't indiscriminate with firing people. Unfortunately, the person who we're facing losing now is a nice, enthusiastic person who always shows up to work, making his loss feel especially confusing to the residents. Of course, we're hindered by the whole only having access to one side of the story.

 

[OldPsychDoc]

How often does this happen at the top programs (you know, the 20 to 30 programs discussed here ad nauseum)?

Begs the question of how and why this happens, particularly on your first two points (incompetence and interpersonal problems).

I'm going to venture a hypothesis that it happens everywhere--but it may be that some of these "top programs" are more vulnerable as they may be selecting residents who are more skilled at academics than they are at interpersonal qualities and life management experience.

 

[sunlioness]

I'm actually surprised it doesn't happen more often--medical training is usually ( in the US at least) a 12 year period in which young adults have put their lives on hold to chase a dream that they understand poorly. .

This is so true. To be honest, I wonder how much of my decision to be a doctor wasn't just because the path was so long and being in school is my favorite thing ever. There are definitely things I know now that I wish I had known and considered at the outset. Maybe I still would have become a doctor anyway, but I would have gone about it in a much more informed and proactive way.

My program had some turnover (including gaining me as a PGY-2), but I never really found it out of the ordinary or excessive. It just felt like life happening. Especially given that my three years of psych residency still stand as the longest I've worked anywhere.

 

[Doctor Bagel]

The really scary thing about this system, though, is that we put all this time, effort and money into this process, and if you have any slip along the way, that's it. There goes your career. There goes your opportunities to pay off the tremendous debt that you accrued, and from what I understand, the job prospects for non-BE/BC physicians are pretty limited. This isn't a job like any other where you can lose it and move on to another opportunity. Maybe we should rethink how we do all of this.

 

[Abider]

I'm scared to death of getting canned at that level, within sight of the finish line. What does one have to do, typically, to make the upheaval to the program worth it to the PD?

Also, I imagine it'd be easy for noise to be there in the data with only 10 or so data points per class...?

 

[m1345]

My other thought is that due to the high stakes, people should be really careful before destroying another physician's career. I'm wondering if some of these things that lead to termination could be remedied with less drastic solutions.

Couldn't agree more. It's one (awful enough) thing to be kicked out of med school for not being able to pass first year, but during residency is just cruel unless the person has turned out to be a psychopath. Although of course we don't want any more incompetent doctors practicing...maybe there needs to be a stricter weeding out process during medical school when the damage is less?

Doc Bagel-- you mention that you only know the situation from one (?the resident's) side. What does he/she say about the reasons for this termination? Was it one awful mistake or a more chronic issue?

 

[twright]

I'm scared to death of getting canned at that level, within sight of the finish line. What does one have to do, typically, to make the upheaval to the program worth it to the PD?

Also, I imagine it'd be easy for noise to be there in the data with only 10 or so data points per class...?

You have to do something really, really, really out of line in order to get kicked out of residency training. Program directors face substantially high-powered incentives to avoid things like this happening, because booted residents (a) create all sorts of problems with regards to service coverage, (b) depress morale among remaining residents, and (c) undermine your ability to attract a strong class the following year due to the general paranoia and conservatism that characterize graduating MS4's.

One of my close friends trained at a highly competitive ob/gyn residency program in New York, and last year they graduated an assassin. (I don't use that term lightly. There were serious concerns not just among attendings but among her fellow residents about patient safety.) There were signals as early as this resident's PGY2 year that she was becoming an assassin, but each class of chiefs just kicked the can on down the road. When she graduated, the program director (who normally helps each resident secure jobs, fellowships, etc) didn't really lift a finger for her -- but that was the extent of any corrective action (and it wasn't really corrective, just punitive). There was never any serious talk of holding her back for remediation or not graduating her. This year there is a budding assassin in the PGY2 class of the same program. They are making half-hearted attempts to remediate her, but in general the entire program is tiptoeing around the issue because the new assassin, like the graduated assassin, is African American and nobody wants to come out and say that the only 2 weak links in the chain in the program's recent 5-year history were the only 2 African Americans.

All of this is to say that, in general, with the obvious program-to-program variation, if a resident gets kicked out, something went really wrong and it probably didn't happen for no reason at all.

 

[NYCMS2]

You have to do something really, really, really out of line in order to get kicked out of residency training. Program directors face substantially high-powered incentives to avoid things like this happening, because booted residents (a) create all sorts of problems with regards to service coverage, (b) depress morale among remaining residents, and (c) undermine your ability to attract a strong class the following year due to the general paranoia and conservatism that characterize graduating MS4's.

One of my close friends trained at a highly competitive ob/gyn residency program in New York, and last year they graduated an assassin. (I don't use that term lightly. There were serious concerns not just among attendings but among her fellow residents about patient safety.) There were signals as early as this resident's PGY2 year that she was becoming an assassin, but each class of chiefs just kicked the can on down the road. When she graduated, the program director (who normally helps each resident secure jobs, fellowships, etc) didn't really lift a finger for her -- but that was the extent of any corrective action (and it wasn't really corrective, just punitive). There was never any serious talk of holding her back for remediation or not graduating her. This year there is a budding assassin in the PGY2 class of the same program. They are making half-hearted attempts to remediate her, but in general the entire program is tiptoeing around the issue because the new assassin, like the graduated assassin, is African American and nobody wants to come out and say that the only 2 weak links in the chain in the program's recent 5-year history were the only 2 African Americans.

All of this is to say that, in general, with the obvious program-to-program variation, if a resident gets kicked out, something went really wrong and it probably didn't happen for no reason at all.

What the heck is an assassin? Is this literal?

 

[twright]

What the heck is an assassin? Is this literal?

Assassin = a resident who is at risk for killing a patient

 

[digitlnoize]

Once again, my program is facing losing another resident, and I just wanted to know how much turnover is in the remotely normal range for a program? 5%, 10%, 20%? Is there a point where it extends beyond bad luck and indicates something about your program? What I do know is that it's ridiculously demoralizing. And about remediation -- does it ever work? My current picture is that if you go the remediation stage, you're pretty much done for. Is that true elsewhere?

And for applicants, no, I won't share where I'm at (although it's not a huge secret). As I honestly have no idea how to conceptualize the turnover we've had, I can't say if it should or should not affect your decision to train at my program.

We've lost ~ 1 a year for a couple years, but they've all been amicable. I even called and talked with the one who left us last year to be sure. The ones we lose are typically people who want to move for some type of family reason, which is what happened last year.

The year before that, we lost someone who transferred to be closer to their spouse who had matched somewhere else. Now we're a little paranoid about couples matches, I think.

As far as remediation, we were told when we started that occasionally they do have someone remediate and it usually turns out fine, supposedly. I just pray every day that it doesn't happen to me.

 

[Doctor Bagel]

In response to twiright's post, the problem is that we're not convinced as a group that this resident has done anything horrible. In fact, all the residents who have worked with him have enjoyed it and described him as a smart, thoughtful, hardworking guy who occasionally has made minor procedural errors with things like documentation (nothing critical -- little stuff that honestly we've all done from time to time). The other concerning thing is that this resident has only been with us a total of about 4 months of work time due to transferring in late last year following another resident attrition issue. Again, though, I only know one side of the story.

Another thing that makes this especially hard for us (aside from all this previous turmoil) is that we actually all get along well together as residents. That's really the huge strength of our program, so seeing a fellow resident suffer eels very personal.

And for applicants regarding attrition -- if this is an issue for you, ask. I'm not saying anything here that hasn't been said a million times before on SDN.

 

[billypilgrim37]

We had a resident in my adult class that was so terrible that none of us could really believe she wasn't fired. She would pray on the floor with patients in the middle of the night in the emergency room (I'm not saying there's no way this could be appropriate, but trust me, in these contexts, it was bizarre), and at the same time got a safety officer fired because they were having sex in the call room. She had more errors and more conflicts with staff and her colleagues than you could count, would jeopardy people on for calls with no good explanation, just wouldn't show up for clinic somedays for no reason. Her lack of boundaries was outstanding. Fortunately, the male residents in my class had enough sense not to sleep with her, but you can't say she didn't try with several of us (regardless of our marital status). They graduated her last year, and we're honestly expecting to see her on the news for some sort of ridiculous misconduct.

So, it varies quite a bit at different programs what it takes to get fired. Short of being the Craigslist killer, I don't think my program would fire you.

 

[psychattending]

As a PD I would say several things:

1) ACGME rules tend to make it hard to just kick out a resident. It would have to be a gross flagrant violation (e.g. sleeping with a patient, selling drugs to a patient), in order to for a program to get rid of somebody quickly. I suspect that most sites have policies and procedures in place to prevent such a thing from happening. Our local policy requires that a resident have a right to appeal a disciplinary activity (e.g. suspension, firing, restriction of ability to practice) and we have mechanisms set up for how the appeal process would work. Since all programs are required to inform trainees of their policies, I would suspect that you could all look up what the specific policies are at your specific program.

2) I would also hazard to guess that most programs are reluctant to fire people because 1) that person can sue and then you have to deal with legal issues for the next couple of years and 2) programs are afraid that they will get a bad rap and then have problems recruiting somebody else.

3) Realize that most PDs are in this business because we like teaching/training people. Thus when we have somebody who is not doing well we see it as our job to get them better.

4) I would think the vast majority of transfers are for personal reasons on the part of the resident - usually family issues, but sometimes wanting a different specialty. These usually happen easily and are pre-arranged with the resident going to another program directly. We once had a resident who transferred into our program because she wanted her training here. However, after a month here she realized that she could not spend time away from her boyfriend and wanted to return to her original program. We were able to work with the Boards and get her back to her original program in a couple of months with no detrimental effects on her training.

5) I do on occasions receive emails/applications from residents who have been let go for other programs. The majority of those are from residents who were not able to pass Step 3 of the USMLE and their program had a policy about them needing to pass Step 3. In the others there was almost always some problem with the resident's performance.

6) In the upcoming Next Accreditation System ACGME is making some changes that could affect things. They are generating a bunch of metrics including how many residents transfer out of program or do not finish a program as well as the Resident Survey. They also will be looking at Board pass rates. Finally they will be looking at Milestone data trying to discern whether programs are helping their trainees improve. These metrics will be analyzed across all programs with the hope that the metrics will show which programs are doing a good job and which are not. Those that appear to be worse (>2 SD?) will attract the attention of ACGME. I used the term "hope" on purpose as there are no data supporting that these metrics will be valid and will do what the ACGME thinks they will do.

7) Off the top of my head I would estimate that in our program over the years only a very small number of trainees have had to leave us because of poor performance (1%?) whereas a larger number (3-5%?) have left for personal reasons (almost always family).

 

[PikminOC]

We had a psych resident get kicked out for boundary issues with a patient or patients. I found out this was the reason years later. I don't think residents are always privy to what the program directors and chairs know.

We had 2 residents go into child psych, so our PGY 3 had to find 2 more residents. One was found who was havg trouble passing the step 3 exam, and the program she was in required that she pass it so she came to ours as a pgy3. one resident transferred for family reasons. one resident replaced him since she was switching fields.

There are lots of reasons for attrition and it is good to know the reason.

 

[Doctor Bagel]

We had a psych resident get kicked out for boundary issues with a patient or patients. I found out this was the reason years later. I don't think residents are always privy to what the program directors and chairs know.

We had 2 residents go into child psych, so our PGY 3 had to find 2 more residents. One was found who was havg trouble passing the step 3 exam, and the program she was in required that she pass it so she came to ours as a pgy3. one resident transferred for family reasons. one resident replaced him since she was switching fields.

There are lots of reasons for attrition and it is good to know the reason.

Hmm, I wouldn't count residents fast tracking as attrition. Here, 4th year is pretty much all electives with no primary call, so we don't need to replace them anyway.

It will be interesting to see what happens when ACGME starts tracking this. Otherwise, I don't feel comfortable sharing any more about this situation publicly.

 

[PikminOC]

I didnt mean to come off like i was asking for more details about your situation. I was just making a generalization regarding med students who are evaluating psych program to know the reason for the attrition rates. or at least as much as they can find out.

 

[Doctor Bagel]

I didnt mean to come off like i was asking for more details about your situation. I was just making a generalization regarding med students who are evaluating psych program to know the reason for the attrition rates. or at least as much as they can find out.

Oh no, I didn't think you were. Just stating that I will refrain from posting any more on the issue with my program.

Conversions about attrition in general remain fair game and incredibly useful.

 

[Doctor Bagel]

I'm thinking I'm in the point where I'm updating my thoughts too much, but I do want to add that I'm not intending this thread to be something to warn applicants away from my program. I think attrition is definitely a consideration when applying to programs, but unfortunately, it's such a complex issue that it's hard to really figure out what to think even if you know attrition data based on all the reasons mentioned above.

If you're interested in positive aspects of my program, please check out other threads I've posted or send me a PM. I certainly have no doubt that I'm getting good training in spite of the stressful past week.

 

[nancysinatra]

We had a psych resident get kicked out for boundary issues with a patient or patients. I found out this was the reason years later. I don't think residents are always privy to what the program directors and chairs know.

Another thing that could happen is that some incriminating information is discovered from a person's past that they hadn't revealed before. Or a credentialing problem of some kind. In those cases an otherwise great resident might be let go.

 

[F0nzie]

Incompetent residents will make your job twice as hard because you're always picking up their slack. Attendings will view the lazy residents as white clouds and hard working residents as a black clouds. The reality is, you've simply been getting slammed with handoffs from your worthless co-resident. I work hard, see all my patients, and do my very best to deliver excellent patient care. I do not have time for incompetent residents that sit on their white clouds brown nosing attendings when there is work to be done. I don't need a trophy for finishing psychiatry residency because I feel good about my work and I am more than happy sitting on my black omnious cloud. I've seen all types of messed up residents and even attendings with severe psychopathology and poor judgment. This phenomenon we are all aware of or obliviously a part of does not end in residency. If anything, this experience will help me make an informed decision with respect to the colleagues that I choose to work with in the future.

 

[Doctor Bagel]

Incompetent residents will make your job twice as hard because you're always picking up their slack. Attendings will view the lazy residents as white clouds and hard working residents as a black clouds. The reality is, you've simply been getting slammed with handoffs from your worthless co-resident. I work hard, see all my patients, and do my very best to deliver excellent patient care. I do not have time for incompetent residents that sit on their white clouds brown nosing attendings when there is work to be done. I don't need a trophy for finishing psychiatry residency because I feel good about my work and I am more than happy sitting on my black omnious cloud. I've seen all types of messed up residents and even attendings with severe psychopathology and poor judgment. This phenomenon we are all aware of or obliviously a part of does not end in residency. If anything, this experience will help me make an informed decision with respect to the colleagues that I choose to work with in the future.

You know, I honestly don't think I work with any incompetent or lazy residents. Well, unless I'm the incompetent, lazy one and am entirely oblivious to that fact. We're all pretty awesome, if I say so myself, and generally have a culture of definitely having each others' backs. That hasn't always been 100% true in the past, but it's changed.

 

[Doctor Bagel]

As a PD I would say several things:

4) I would think the vast majority of transfers are for personal reasons on the part of the resident - usually family issues, but sometimes wanting a different specialty. These usually happen easily and are pre-arranged with the resident going to another program directly. We once had a resident who transferred into our program because she wanted her training here. However, after a month here she realized that she could not spend time away from her boyfriend and wanted to return to her original program. We were able to work with the Boards and get her back to her original program in a couple of months with no detrimental effects on her training.


7) Off the top of my head I would estimate that in our program over the years only a very small number of trainees have had to leave us because of poor performance (1%?) whereas a larger number (3-5%?) have left for personal reasons (almost always family).

You make your program sound like a nice place to train. I especially appreciate that you were willing to work to get a resident back to a better spot for her even though I imagine the transfer was an inconvenience for your program. We all want to train at places where we feel like our bosses have our back in some way.

 

[LEdaddy]

If it's happening year after year, there must be a problem in the selection process and/or the way the program portrays itself vs how it really is. For example, the program where I went to med school portrayed itself as laid back and mellow, but actually was as demanding as other more competitive places that made their high level of expectations for performance and hard work very clear on interview day. As a result, the program lost 1-2 residents each year and I think the above issues played a factor in their departures.

 

[Doctor Bagel]

If it's happening year after year, there must be a problem in the selection process and/or the way the program portrays itself vs how it really is. For example, the program where I went to med school portrayed itself as laid back and mellow, but actually was as demanding as other more competitive places that made their high level of expectations for performance and hard work very clear on interview day. As a result, the program lost 1-2 residents each year and I think the above issues played a factor in their departures.

You know, this is certainly an issue, and might in part be explained by our geographic location. It's certainly something to think about in recruitment -- I know here I felt like I worked harder as an intern than I anticipated, and that led to some bitterness. Of course now I work less than a lot of 3rd year residents thanks to our super front-loaded call system, but that doesn't prevent burnout in the 1st and 2nd years.