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What is meant by "Malignant Residency Program"?
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Prett sure m&m is one of the only things exempt from legal proceedings
You are correct.
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Actually that's covered, things said in an m&m are off limits to subpoenas etc. As they did not want doctors to be unable to learnfrom mistakes, improve systems etc. Now if you record it, or talk about it to someone else after the m&m the you can have troubles.
Our IM dept has M&M once a month that usually includes 2 different cases. Once a quarter, it's a combined EM/IM M&M which is always a rollicking good time.
Actually in most states im pretty sure you can record it or keep minutes and those still can't be used in legal proceedings.
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You ask me like I know 😛 I'm in surgery. We have weekly M&Ms.
Yeah, I'm pretty sure OB/gyn could have a pretty regular M&M as well.
That's my understanding as well.
cardiology has M and M.
Internal medicine...not so much. If we had M and M on every patient who died on the medicine service, there wouldn't be time to have any other educational conferences...barely kidding. The thing with internal medicine is that there are huge numbers of geriatric patients and who die from reasons that are multifactorial, and commonly are "expected" deaths, even though we try to fight them off. There is often nobody to "blame", per se.
Internal medicine...not so much. If we had M and M on every patient who died on the medicine service, there wouldn't be time to have any other educational conferences...barely kidding. The thing with internal medicine is that there are huge numbers of geriatric patients and who die from reasons that are multifactorial, and commonly are "expected" deaths, even though we try to fight them off. There is often nobody to "blame", per se.
This^. In IM, the vast majority of deaths are due to the inexorable progression of disease. Sure...we F up as often as people in other specialties but since we're not (usually) doing it with sharp things inside of people, the result of these errors tends to be less dramatic (although not always).
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I certainly don't think that discussing every death is necessary, but I know you have complications. Someone could have an unexpected adverse drug reaction, or they might not respond to traditional therapy. I know a patient who developed a spontaneous retroperitoneal hematoma (on appropriate therapeutic anticoagulation) and died while on the medicine service. Some of these things would be beneficial to discuss.
Our M&Ms are often on things that don't seem too exciting, like a nowhere-near-obstructing PE, post-op intra-abdominal abscesses, etc. It's not like we're leaving retractors in patients or accidentally killing them left and right.
I thought this thread about M&M Vs Malignant Residency Programs. Its human to slip away and remember nations have short memory compared to computers.
What?
A lot of this kind of stuff gets covered in morning report and regular conferences. The vast majority of morning report conferences that I went to start with a complicated/sideways case and present to discussion of management...often with a healthy dose of retrospectroscopy.
I think we probably end up discussing the same kind of stuff the surgeons do, we just don't call it M&M.
And I didn't mean to imply that surgeons are killing folks off left and right, just that when it does happen, there's often an obvious inciting incident to use as a nidus for discussion.
A few things worth noting:
M&Ms are not merely forums to lay blame. A complication isn't always due to someone's mistake - technically speaking, they should account for any significant deviation from a patient's expected trajectory. Thus, a wound infection, or ventilator-associated pneumonia, or DVT, even if treated/prophylaxed correctly, can still end up as a complication.
Surgical M&Ms don't always talk about "mistakes" made in the OR, though technical misadventures do occasionally get presented. Rather, they can deal with the more medical (see above) or problems with post-op management. Rarely do you hear about some disastrous move that occurred intra-op.
There's also a difference between discussing individual errors (e.g. "I closed the skin on a contaminated case and the patient developed a wound infection") and system errors (e.g. "the patient was hemorrhaging during an open AAA repair and our blood bank couldn't keep up with blood losses").
M&Ms are not merely forums to lay blame. A complication isn't always due to someone's mistake - technically speaking, they should account for any significant deviation from a patient's expected trajectory. Thus, a wound infection, or ventilator-associated pneumonia, or DVT, even if treated/prophylaxed correctly, can still end up as a complication.
Surgical M&Ms don't always talk about "mistakes" made in the OR, though technical misadventures do occasionally get presented. Rather, they can deal with the more medical (see above) or problems with post-op management. Rarely do you hear about some disastrous move that occurred intra-op.
There's also a difference between discussing individual errors (e.g. "I closed the skin on a contaminated case and the patient developed a wound infection") and system errors (e.g. "the patient was hemorrhaging during an open AAA repair and our blood bank couldn't keep up with blood losses").
I think it was something in there about how it was interesting how the thread got off topic on M&M rather than the malignant programs. And them maybe that it was human nature and we have shorter term memory than computers?
Anyway, I think that it's a better topic than malignant programs. I think that the definition of "malignant programs" is just like porn - you know it when you see it.
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My experience with surgical M&Ms is largely (completely) informed by my experience as a med student at an NYC program where laying blame seemed to be the only point. I don't doubt that good surgery programs are more interested in bringing up mistakes/complications as real learning opporutnities. In fact, at my current institution, the better attending surgeons will often bring up these issues during tumor boards and discuss the ways in which it affects downstream care of our shared patients.
Which kind of gets back to my previous point. We talk about the same stuff in IM (and probably in FM and Peds)...we just call it something different.
I think if you don't have a set forum and time when complications get discussed, you lessen the impact and lose a lot of the value. Squeezing it into a morning conference where other topics are the primary focus marginalizes it. The point of M&M is that the focus of the meeting is the complications. Surgery and other Similar fields intentionally separate this out because its regarded as something too important to be squeezed in with other topics. No question this kind of stuff gets discussed in other specialties, but when you try to squeeze it into other forums, like morning conference, it has very much a "by the way" feel to it and loses much of it's impact.
And that's unfortunate. A well-organized M&M conference tends to be one of the most educational sessions for the residents.
We had M&M once a month during IM residency. Usually the case was presented by a third-year resident who wasn't even involved, and the names of the team and consultants involved were kept anonymous, so as to prevent any finger-pointing. Most of the cases tended to be of patients who had a rather complicated hospital course and ended up having expected deaths. Although, when it was my turn to present, mine was actually a patient who had been relatively healthy on admission, and for whom discharge was being planned when she suddenly expired.
"Malignant program" means that it's wicked awesome and that you should go there. It's just American slang, bro. Don't listen to the haters here trying to tell you the opposite.
And was an autopsy performed to try and figure out why?
I think the family refused the autopsy, I'm not really sure though.
And therein lies a fundamental difference in the purpose of the M&M - in surgery, the importance in standing up there and "taking your lumps" when you talk about your own complication is a big part of the conference. You're supposed to talk about what went wrong, what you learned from your experience, what the data shows and how you would act in the future.
To be honest, I'm not sure which method would be better. You could argue that if you presented your own case in M&M, it would force you to be held accountable for your own errors, which should be the case for physicians. However, if you did present a case that you weren't involved in, in which the team involved was kept anonymous, I don't think it would necessarily diminish the educational value. Potential errors and debatable points in management would still be discussed, and everyone could potentially learn from the case, so that they would not commit the same errors.
You are never going to defend others actions as zealously as you would your own. And there's always a difference in quality of learning based on presentation. Someone passively saying here's what they did, Is never going to have the same import as here's what I did. You aren't going to have that heated passionate debate that provides the most memorable and poignant learning as you would if someone takes ownership. This is why surgery hasn't changed the format in over a century. And why few other specialties find their own M&M to have the same import.
Another problem with an uninvolved third-party presenting the complication is that if they're asked specific questions about the case, they won't be able to answer. (For example, "Why did you choose to leave a drain in this patient?"..."Uh, I don't know, I wasn't there.")
These are all valid points. But one thing I've noticed, at least in my field, is that complications can rarely be traced to the error of any one resident, or even team. Usually there tend to be multiple factors at play.
For instance, most of the patients who did not survive tended to be elderly, with numerous comorbidities (i.e. HTN, DM, COPD, etc...), and also of lower socioeconomic status. So the deck is already stacked against them even from the time of admission.
In addition, you have to account for the fact that the patient goes through several echelons of care, even from before the time of admission. You have to account for what the EMT's/paramedics did, the initial tests and treatment ordered by the ER physician, how well the patient was screened and triaged by the third-year admitting resident, the orders written by the admitting team, and also for how well the patient was followed by the floor team and any further management by the floor team. The team who admitted the patient and the floor team are not necessarily the same thing. Often whomever was on call the previous night will admit the patient and the floor team will take over the next day. Because of so many handoffs that occur in patient care, the potential for errors is really endless. Not to mention the potential breakdowns in communication that occur, which prevent appropriate tests and treatment from getting done, even when ordered. Finally, a large proportion of these patients end up going south on the floor and have to go to ICU, which means a whole new set of orders has to be written.
So in my opinion, most of the time a complication that occurs cannot really be traced to what any one physician did. Its very difficult to say that any one resident's error caused the demise of the patient. But errors made at various points in the system could have contributed to the death. I'm not saying that we should not be held accountable for whatever errors we made in the care of the patient. But usually when a patient expires, there are multiple factors involved.
For instance, most of the patients who did not survive tended to be elderly, with numerous comorbidities (i.e. HTN, DM, COPD, etc...), and also of lower socioeconomic status. So the deck is already stacked against them even from the time of admission.
In addition, you have to account for the fact that the patient goes through several echelons of care, even from before the time of admission. You have to account for what the EMT's/paramedics did, the initial tests and treatment ordered by the ER physician, how well the patient was screened and triaged by the third-year admitting resident, the orders written by the admitting team, and also for how well the patient was followed by the floor team and any further management by the floor team. The team who admitted the patient and the floor team are not necessarily the same thing. Often whomever was on call the previous night will admit the patient and the floor team will take over the next day. Because of so many handoffs that occur in patient care, the potential for errors is really endless. Not to mention the potential breakdowns in communication that occur, which prevent appropriate tests and treatment from getting done, even when ordered. Finally, a large proportion of these patients end up going south on the floor and have to go to ICU, which means a whole new set of orders has to be written.
So in my opinion, most of the time a complication that occurs cannot really be traced to what any one physician did. Its very difficult to say that any one resident's error caused the demise of the patient. But errors made at various points in the system could have contributed to the death. I'm not saying that we should not be held accountable for whatever errors we made in the care of the patient. But usually when a patient expires, there are multiple factors involved.
I think you are not isolating out complications/errors from end result here. Sure there may be patients with multiple comorbidities taken care of by multiple people who ultimately don't do well and wouldn't do any better in a perfect system. But that doesn't mean there weren't one or more complications/errors that happened during their hospitalization that you can isolate and discuss and learn from. M&M isnt solely about " I did this and the patient died because of it". You can have complications where the patient did fine, and you can have complications where a patient still died from something unrelated -- you still need to learn from those errors. There is no " no harm no foul" exception to medicine. So if you trashed a patients kidneys, but he died of a GI bleed, the trashing of his kidneys is still a ripe subject for M&M. The fact that there are multiple factors and players at work is not a good argument that your role shouldn't be scrutinized.
Oh, don't get me wrong. Yes, there are errors that may occur in a case that should be scrutinized. I agree with you there. This is what I said we should be held accountable for. This is what we did discuss in our M&M, so that we could all learn from them. My point was more along the lines of whether you could correlate most deaths with a specific isolating event. I was only trying to point out the ambiguity of doing so. But I'm in no way saying that we shouldn't look at any errors that occurred and learn from them. That is where the value of M&M is.
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We in surgery at my program don't have nearly as many handoffs as you describe. You admit the patient and you usually follow them, to the OR, the ICU and back to the floor. Responsibility is a more direct line.
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How does one find out which programs are malignant before applying? It seems it would be difficult to look into each one prior to applying... I wish SDN had a thread for each field listing malignant programs ... 😉
There is another thread, right on this page, discussing this same topic:http://forums.studentdoctor.net/showthread.php?t=713138
The answer is that there is no clear "definition" of malignant. One person declares a program malignant. Someone else at that program says it's fine, and that the complainer is simply angry/vindictive/etc. Some programs may terminate more residents than others -- does that mean they are "malignant"? Maybe, or maybe they just have tougher standards to which they hold. Or maybe they take weaker residents (giving them a chance) and then have a higher rate of failure. Who knows?
Some people look at it by workload. One program has you managing 20 patients at a time. Another only has you managing 12. Is the one with 20 malignant? Or perhaps they simply think that managing more patients teaches you more -- and maybe it does?
Some look at it by ancillaries -- how much support is there for residents? Do they have to do their own blood draws, or schedule appointments, etc?
Really in the end it comes down to how residents are treated. If they are treated with respect, that's good. If they are treated with disdain, contempt, or indifference, that's going to lead to problems. But getting anyone to agree even on this is impossible.
The answer is that there is no clear "definition" of malignant. One person declares a program malignant. Someone else at that program says it's fine, and that the complainer is simply angry/vindictive/etc. Some programs may terminate more residents than others -- does that mean they are "malignant"? Maybe, or maybe they just have tougher standards to which they hold. Or maybe they take weaker residents (giving them a chance) and then have a higher rate of failure. Who knows?
Some people look at it by workload. One program has you managing 20 patients at a time. Another only has you managing 12. Is the one with 20 malignant? Or perhaps they simply think that managing more patients teaches you more -- and maybe it does?
Some look at it by ancillaries -- how much support is there for residents? Do they have to do their own blood draws, or schedule appointments, etc?
Really in the end it comes down to how residents are treated. If they are treated with respect, that's good. If they are treated with disdain, contempt, or indifference, that's going to lead to problems. But getting anyone to agree even on this is impossible.
It spreads beyond the basement membrane
You must must must tap into the alumni from and clinicians at your home school to find this kind of thing out. This is a small, word of mouth profession. And malignancy tends to change every few years, based on who is the PD, Chairman, etc at various programs, so something etched permanently in the Internet tends to be a bad idea. You need to talk to people, to get the buzz.
I think malignancy isn't as nebulous as you suggest. One persons view of his personal situation is irrelevant -- there are many reasons to be frustrated in residency, and that doesn't make a program malignant. However if most of the residents at a program feel abused, that is something quite different. I totally agree with your last couple of sentences -- malignancy usually is a top down phenomena -- whether the higher ups view the residents as future colleagues and treat them accordingly, or whether they simply regard them as whiny cogs in the machine, to abuse at will. I think some of the other things you describe, such as terminations, long hours, lack of support staff can be symptoms of a malignant programs, but they are nonspecific, and you can have any of these in very benign programs as well. For instance working long hours at a place where you are treated with a lot of respect and regularly taught isn't malignant, it's just residency. Nor is a place malignant because it terminates a resident who cannot meet the requirements of the job after multiple meetings and chances to remediate. And being at a place where you have to place your own lines, etc might be annoying, but that's hardly malignant. But certainly a place where they treat you badly, work you hard, fire the complainers, and scut you out to save a buck on nursing COULD be malignant. Again, it's not really in the eye of the beholder -- it's an objective view by all beholders in the program. But there isn't one single component you can point to and say, yeah he had to wok 80 hours per week every week, it must be malignant. It's not as neat and clean and numeric as that.
Ba dum ch
Unless it's maligant in-situ and still somehow spreads to the lymph node, like the miraculous metastatic DCIS.
To answer the OP's question, pay really close attention at the interview. I think that's your best best.
with the caveat that interview day is a Lot like being a tourist in the old Soviet Union -- you only see the places and people they want to show you. It's the ones that are hidden that have the real story.
This thread is sufficiently similar to the other mentioned that I've merged the two. Please feel free to continue the discussion.
i've seen people on sdn go on medical leave in prelim programs not get to finish what they missed, because the program doesn't allow them to. it seems that is what most programs do, malignant or not. isn't that a bit harsh? the intern then has to repeat the year and finish it if they want to have a valid pgy1 behind them. then having a past residency behind them makes it hard for them to get another residency. that behavior by programs seems malignant.
This is a tough situation. I have X prelim spots. If you complete 1/2 the year and then go out on medical leave for the other half, I have no easy way to "save" you a spot. If I put you in a spot and you stay for 6 months, then I'm short an intern for 6 months (as I'm unlikely to find a good quality intern for only half a year, and unless they only need 6 months of training I end up with the same problem next year). So, yes, many programs may do this, simply because the other choice (not matching their full complement of new interns) is a big problem.
Makes sense, but I wish that residents could complete what they missed instead of having to redo everything all over again on a clean slate. That would save a lot of medicare money. I wonder if some of their months of funding could be saved so they can continue the next year at that program and complete everything. One extra resident on board for the next year for a little while can't hurt can it? And im not talking 6 months, even only 1-3 months is what most people probably only need to finish. They should make residency like college credits so you can save your credit. The way it is right now is ridiculous. People get sick, have family problems, etc. we are all human, but the system doesn't cater to those who have common human problems. I think things like this in the system should be fixed. It could save a lot of money so no one would have to repeat anything, they could just continue where they left off, if within reasonable limits.
As usual, it's complicated.
if someone only has 1-3 months to finish, then usually I can simply extend their residency into the next year and still fill all of my usual slots. I'd need to file a request with my RRC for a temporary cap increase, and as long as I'm not on probation or anything it would be approved. Funding the extra 1-3 months totally depends on whether my institution is at it's "cap" (which is totally different than my RRC training cap). if the institution is at it's cap, then extra residents are not funded. If it's below the cap, then it is funded.
Usually when an individual story is explored on SDN, it's not that the program couldn't extend training, it's that they didn't want to. The contract ends in June, and they simply don't extend it. Usually this is because there were performance issues on top of whatever the LOA was about.
To me, the most close definition is "forcing residents into wanting to quit". I want to tell you about my current experience in a residency program and how they are treating my friend who is a US graduate but born abroad. She came here as a refugee, finished medical school in a top school, and came to University of Vermont, Fletcher Allen Hospital for Internal Medicine residency. She is a smart and very nice person. After 8 months of maltreatment, including sending her for an OSCI exam with their medical students and even sending her for intelligence test to rule out learning disability!! they finally told her they would not give her credit to go to the 2nd year, not in their program not anywhere else and they are would not extend her first year in our program either. We are all very upset about how she has been treated and obvious discrimination against her from a few of third-year residents and attendings. There are some attendings and residents who are supportive but our PD believes people who write good evaluations about residents want to be "nice" but those who say bad things are "honest" people who want to help residents to improve!
OK, i'll bite because of the level of detail in the post.
I am sorry about what happened to your friend. The program could be trying to sham her out of a medical career. The OSCI is subjective given that a large component of the score is given by lay actors in need of a paycheck. They can be influenced. This possibility increases in a situation where the program is not renewing her contract or trying to kick her out of the program.
When used appropriately, the OSCI can help performance. However, it can be used to sham a resident into being incompetent. Also, I would worry about that "intelligence test". No way a graduate of a U.S. medical school suddenly becomes mentally incompetent. The exam is an ambush and is easily manipulated with the services of a willing neuro-psychologist. He can cast the net widely or narrowly depending on the situation. The program is using that test as a gateway for psychologic or psychiatric evaluations that will most likely be used against her. Unfortunately, the results of those evaluations are usually protected by privilege. She will have a hard time obtaining the reports without extensive litigation. Ironic isn't it. The evaluation is supposed to help the resident but she cannot have access to it to get "helped".
I would read Ms. Klaiman's article about medicine's dirty little secret. After all these years, it looks like they are still playing the same game.
Tell her good luck and keep the faith. One day, things will change.
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