What should i do now..terminated from the program

[satakay]

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I joined my program as PGY2, later that academic year one of my evaluation came negative for some rediculous reason..anyhow I was placed on probation and the PD was telling me that this is nothing serious and in the extreme situations, you will need to repeat max of six months of your residency..
I never heard of this probation thing before as new in this country and in the system, so I took it light..but having said so..they also terribly abused me during my probation period, and made me to do calls for almost every week end for every body, and on top of it, they made me to do an extra ICU rotation while on probation...towards the end of the probationary period they cut my probationary time 15 days and terminated me one day before the expiration of my contract..
I grieved that decission, and was re-instated.
to make it short...the program outlined a remediation program for three months, and they set fort 10 criteria, one of the criteria was to meet the PD in the ist week of my remediation period..and discuss with him my plans...
I tried multiple times that week but, was told that PD is busy in the interviews or meeting..and finally I met him during the 2nd or 3rd week of my so called remediation period..
I did well this time, all my evaluations were either excellent or good with good remarks..they also made me take shelf test for students as well as midclerkship exam..on which I did well too..

In the end the program director asked me to resign, I declined bc I thought I achieved their expectations and they wont be so cruel to destroy my whole career...
But I was wrong they terribly destroyed me. I spent almost two years in PGY2 ..and in the end I was terminated recently and denied to give me any credit, bc I did not meet the criteria for not being able to meet with the PD durng the ist week of my remediation period..

I request every body to give me honest advise whether my career is over or I still have some hopes..
Bc whoever PD I will tell this story will not keep me obviously...once you are terminated from the program..
Thanks a lot and looking forward for you kind advice..

 

[DarthNeurology]

I joined my program as PGY2, later that academic year one of my evaluation came negative for some rediculous reason..anyhow I was placed on probation and the PD was telling me that this is nothing serious and in the extreme situations, you will need to repeat max of six months of your residency..
I never heard of this probation thing before as new in this country and in the system, so I took it light..but having said so..they also terribly abused me during my probation period, and made me to do calls for almost every week end for every body, and on top of it, they made me to do an extra ICU rotation while on probation...towards the end of the probationary period they cut my probationary time 15 days and terminated me one day before the expiration of my contract..
I grieved that decission, and was re-instated.
to make it short...the program outlined a remediation program for three months, and they set fort 10 criteria, one of the criteria was to meet the PD in the ist week of my remediation period..and discuss with him my plans...
I tried multiple times that week but, was told that PD is busy in the interviews or meeting..and finally I met him during the 2nd or 3rd week of my so called remediation period..
I did well this time, all my evaluations were either excellent or good with good remarks..they also made me take shelf test for students as well as midclerkship exam..on which I did well too..

But I was wrong they terribly destroyed me. I spent almost two years in PGY2 ..and in the end I was terminated recently and denied to give me any credit, bc I did not meet the criteria for not being able to meet with the PD durng the ist week of my remediation period..

Well, it is hard to say what happened based on just your side of the story, I doubt that it was just because you didn't meet with the PD the first week (they probably put down something else in your file), BUT if they absolutely required you to meet with the PD the first week and if you realized you couldn't then you needed to really try harder and track down the PD in the hallway and report to someone that the PD is ignoring you, sadly it is too late now.

It will be somewhat hard to finish residency, but you can do it if you can find another program to take you on as a PGY-2, this is easier to find than a PGY-1 I think at this point as people drop out for various reasons. What happens in the next couple years is more chance than anything else, i.e. if there is a spot available and if you connect with a PD who can see your side.

It is great that you were able to get re-instated, but I think that at that point the PD was against you and therefore you couldn't have done anything right to save your career at that point. There is a lot of politics in medicine, especially internal medicine residency which is very subjective for some reason.

If you got a negative eval it might be for a "ridiculous reason" BUT the attending who wrote the negative eval obviously has a low opinion of you, . . . and in the world of politics in medicine that IS a problem.

 

[frank51]

I agree with the above poster, what specialty were you pursuing?

 

[satakay]

Thanks a lot for your replies: I know its hard to believe, but the only thing I got was that I did not meet this citeria of my remediation and failed to understand the purpose of remediation. which honestly speaking I still dont, bc I dont see what impact it would have had on my academic career...
But I guess it was pre-planned bc the PD was avoiding me to meet him, and his sec. is well aware of it..
I dont mean that I,m completely innocent, bc I got negative evaluation, which has been exagerated or wahtever, but I fixed that issue and got got evaluations subsequently......I wont go in details or blaming thing..
I am in trouble whatever may be the reason...my fault or their...but the sufferer is me anyway..
And now I have no idea what to do..where to go..
what to say other programs..
is there any point for applying to another Internal Medicine program or not..
Screwed up..man have no idea what to do..

 

[satakay]

I was in Internal Medicine..........unfortunately..and on top of that belong to a place,which is mainly viewed hostile in the US...
I personally know many others who had negative eval..but they were not kicked out..
I also know that people could not pass their step 3 and their training was prolonged but did not kicked out..
I was so much humaliated during all this process......which I wont even mention..
bc I will be my side of story anyway..

By the way I can publish those cretiria as well as their response to my performance..so you guys could believe..

 

[frank51]

Just from what you're telling us it seems that they just didn't like you, and wanted you out, it may have been a combination of things, including your nationality, unfortunately. The good news is that there are always IM spots available, people change their mind about their specialty for a variety of reasons, there might also be websites that will help you in finding open spots. The hard part is explaining your situation to them, be honest, present any supporting documents you may have, and try to put this whole thing behind you.

 

[jigga]

First of all you are eligible for continuing your residency albeit at a new place.

Now finding that position is going to be an uphill task but not impossible. And where ever you go, the new program director will require a letter from your previous program director. And this depends upon whether you still maintain the sort of relations with your previous program that might help in extracting a letter. And even if you get one, it is not going to hold any beneficial information for you. So your best bet will be to get the new PD to believe in you and just get the letter for the formality.

As you said that you were new to this system, so i suppose you are an IMG. So whether you can start your PGY2 again or not depends upon your visa status. If your previous PGY1 & PGY2 years were on a J-1 visa, then there are going to be funding issues and you cannot repeat your PGY1/PGY2 in a funded position at another place even if you want to. If you were working on a H1 visa then i think repeating a PGY2 or even PGY1 (if you even have to take that extreme step) is possible if you get a position some where. On H1 the hospital does not get/utilizes govt funding for the resident.

I might be wrong. Maybe others with more knowledge can help/advice in a better way.

Which criteria(s) of their remediation policy were held against you?

 

[satakay]

Thank you friends..I am a green card holder...and do not have visa issues..but I dont know about this funding stuff either..

And the criteria they held against me, was the only one ..for not being able ot meet the Director in first week of my remediatiion plan..otherwise they put me go through a huge load of work, to write many documents, meet three mentors and on top of that put in the bussiest rotations again, even the director denied to grant me one week for preparation of the shelt test, bc as you know I did my step-2 a while ago..but inspite of that I did well on that test..
They intended to kick me out what ever the reason was..either my fault or somebody else...but I am in hell now anway..and have no idea waht is going to happen to me..

 

[jigga]

There is a topic "terminating residents" in the general residencies issues subgroup. Just scroll through that and you might find a member who was or might be still in a similar position as you. Getting in touch with them will certainly help you. I do not excatly remember whether the threaD had any actual terminated residents but good info none the less.

And regarding the criteria you mentioned.. Well when they have decided to terminate a resident, they just bid for time to make their case strong so that they are not in a weak position if the resident comes bacK at them legally.

 

[NotAProgDirector]

I joined my program as PGY2, later that academic year one of my evaluation came negative for some rediculous reason..anyhow I was placed on probation and the PD was telling me that this is nothing serious and in the extreme situations, you will need to repeat max of six months of your residency..

I worry that the problem here is poor communication. Probation = warning that you will be fired if you do not do better. There is no way that probation is "nothing serious". It's impossible for me to tell if your PD told you this, or this is the way you interpreted what your PD said.

The tone of this post makes me worry that you really believe that your performance is fine and that this whole process is unfair. And, that is certainly possible. More likely, however, is that your performance is not fine and that you have not taken ownership of this, addressed it, and fixed the problem.

I never heard of this probation thing before as new in this country and in the system, so I took it light..but having said so..they also terribly abused me during my probation period, and made me to do calls for almost every week end for every body, and on top of it, they made me to do an extra ICU rotation while on probation...towards the end of the probationary period they cut my probationary time 15 days and terminated me one day before the expiration of my contract..

It is neither reasonable nor fair to "punish" someone while they are in probation. However, I sometimes adjust schedules for people who are in probation. In general, residents who are struggling do poorly in their inpatient blocks and their continuity practice. Rarely do I see a struggling resident get a poor evaluation from an elective. So, when building a probation schedule, I'll put together rotations which will both give the resident the maximal chance of success (by looking at their strengths/weaknesses and choosing rotations) and give me a reasonable set of data to evaluate them. Sometimes this includes additional call blcoks. Covering for other people over the weekend is simply mean and counterproductive (unless the only weakness is "cannot cover other services over short periods of time well")

I grieved that decission, and was re-instated.
to make it short...the program outlined a remediation program for three months, and they set fort 10 criteria, one of the criteria was to meet the PD in the ist week of my remediation period..and discuss with him my plans...
I tried multiple times that week but, was told that PD is busy in the interviews or meeting..and finally I met him during the 2nd or 3rd week of my so called remediation period..
I did well this time, all my evaluations were either excellent or good with good remarks..they also made me take shelf test for students as well as midclerkship exam..on which I did well too..

In the end the program director asked me to resign, I declined bc I thought I achieved their expectations and they wont be so cruel to destroy my whole career...
But I was wrong they terribly destroyed me. I spent almost two years in PGY2 ..and in the end I was terminated recently and denied to give me any credit, bc I did not meet the criteria for not being able to meet with the PD durng the ist week of my remediation period..

As described, this is completely unacceptable. I'm sure your PD has another side to the story, and I bet the truth lies somewhere in between.

The honest truth is this: If you are evaluated and found to have a weakness, even if you disagree in general the best thing to do is to take responsibility, ask for help to improve, come up with an improvement plan, and do it. Although I'm sure there are exceptions, I bet that in most cases where a resident is put in remediation/probation for something which they feel is not accurate, that the problem is real (to some extent) and they can't /won't see it. Denying the problem usually only amplifies the response, and you end up with things getting blown way out of proportion.

In reading your post, as mentioned above, I bet your termination had less to do with whatever you did (or didn't do) and more with your response to their concerns.

If your previous PGY1 & PGY2 years were on a J-1 visa, then there are going to be funding issues and you cannot repeat your PGY1/PGY2 in a funded position at another place even if you want to. If you were working on a H1 visa then i think repeating a PGY2 or even PGY1 (if you even have to take that extreme step) is possible if you get a position some where. On H1 the hospital does not get/utilizes govt funding for the resident.

I might be wrong. Maybe others with more knowledge can help/advice in a better way.

So, turns out this isn't correct, but does highlight some important points.

Visas have nothing to do with funding. All residents, regardless of visa status, are funded by the government. However, if the OP was on a visa, then they would have a serious problem. Both J and H visas are emplyment visas -- if you lose your job, your visa evaporates (there is a short grace period). Luckily, this does not apply to the OP.

Funding is a complex issue. All residents are capped for funding at the minimum time to allow for board certification in the first field trained. Hence, assuming the OP did a PGY-1 in prelim medicine or surgery, once they start an IM residency they are capped at 3 years of full funding. The OP has used most of the three years -- one for the PGY-1, and at least 1.5 for this PGY-2 which they may not be getting crdit for. Once three years are used, the OP's program will only get partial funding. Some programs will not look favoribly on this. Some will not care. There is nothing the OP can do about it.

 

[satakay]

Thank you very much dear program director: Let me agree with you. because accusing them, will not solve my problem, rahter accepting everything on myself..and infact it is my issue not theirs, bc its my career and life..My program destroyed me with good intentions or bad doest matter now.
But what are my chances now?
and what should I do to get into anther program with full spirit and work on all mistakes or issues I had previously..but who is going to trust me..
How can I move on, now?

thank you very much and looking forward for your kind advise

 

[FatKid]

I joined my program as PGY2, later that academic year one of my evaluation came negative for some rediculous reason..anyhow I was placed on probation and the PD was telling me that this is nothing serious and in the extreme situations, you will need to repeat max of six months of your residency..
I never heard of this probation thing before as new in this country and in the system, so I took it light..but having said so..they also terribly abused me during my probation period, and made me to do calls for almost every week end for every body, and on top of it, they made me to do an extra ICU rotation while on probation...towards the end of the probationary period they cut my probationary time 15 days and terminated me one day before the expiration of my contract..
I grieved that decission, and was re-instated.
to make it short...the program outlined a remediation program for three months, and they set fort 10 criteria, one of the criteria was to meet the PD in the ist week of my remediation period..and discuss with him my plans...
I tried multiple times that week but, was told that PD is busy in the interviews or meeting..and finally I met him during the 2nd or 3rd week of my so called remediation period..
I did well this time, all my evaluations were either excellent or good with good remarks..they also made me take shelf test for students as well as midclerkship exam..on which I did well too..

In the end the program director asked me to resign, I declined bc I thought I achieved their expectations and they wont be so cruel to destroy my whole career...
But I was wrong they terribly destroyed me. I spent almost two years in PGY2 ..and in the end I was terminated recently and denied to give me any credit, bc I did not meet the criteria for not being able to meet with the PD durng the ist week of my remediation period..

I request every body to give me honest advise whether my career is over or I still have some hopes..
Bc whoever PD I will tell this story will not keep me obviously...once you are terminated from the program..
Thanks a lot and looking forward for you kind advice..

OP, did you graduate from a US M.D. school?

 

[satakay]

no I am an IMG..

 

[psymed]

Satakay.........my thoughts are with you. Hope you can find the answers to your questions. Whatever the truth may be, it is always sad to read such posts. Good Luck!

 

[FatKid]

no I am an IMG..

You need to apply broadly to family medicine residencies. In my opinion, FM is your best bet, especially since you are IMG.

 

[NotAProgDirector]

Thank you very much dear program director: Let me agree with you. because accusing them, will not solve my problem, rahter accepting everything on myself..and infact it is my issue not theirs, bc its my career and life..My program destroyed me with good intentions or bad doest matter now.
But what are my chances now?
and what should I do to get into anther program with full spirit and work on all mistakes or issues I had previously..but who is going to trust me..
How can I move on, now?

thank you very much and looking forward for your kind advise

You need to decide what field of medicine you plan to pursue. FM, IM, and path are probably the least competitive. PM&R is another option.

If you really don't know why you failed out of your last program, I would consider asking to meet with the PD again to find out, honestly. Make it clear that the meeting is NOT to beg for your position back or ask for another chance, but that you want to grow from this and you would really like to know what you did poorly.

You need to apply very broadly. You might need to be willing to repeat your PGY-1. You need to be willing to move anywhere in the US.

You should seriously consider wherever you did your PGY-1. If they liked you, perhaps they'd take you back.

If you get some feedback from your last PD, I would then consider contacting your PGY-1 PD to see if the same issues were there. If it was just a prelim year, they may have simply passed you through to get you done and out. It happens.

 

[satakay]

thank you very much

 

[SouthernSurgeon]

The tone of this post makes me worry that you really believe that your performance is fine and that this whole process is unfair. And, that is certainly possible. More likely, however, is that your performance is not fine and that you have not taken ownership of this, addressed it, and fixed the problem.
.

I have to say...if a program is making a PGY2 take the third year medical student shelf exam...this indicates to me that they are seriously concerned about a knowledge deficiency (or they are just plain cruel).

 

[DarthNeurology]

I worry that the problem here is poor communication. Probation = warning that you will be fired if you do not do better. There is no way that probation is "nothing serious".

So, when building a probation schedule, I'll put together rotations which will both give the resident the maximal chance of success (by looking at their strengths/weaknesses and choosing rotations) and give me a reasonable set of data to evaluate them. Sometimes this includes additional call blcoks. Covering for other people over the weekend is simply mean and counterproductive (unless the only weakness is "cannot cover other services over short periods of time well")

Denying the problem usually only amplifies the response, and you end up with things getting blown way out of proportion.

In reading your post, as mentioned above, I bet your termination had less to do with whatever you did (or didn't do) and more with your response to their concerns.

The thing that gives this resident some credibility is that he/she got kicked out of residency --appealed it however--, and then got back into the program!! There MUST have been some other attendings that looked at what the PD was doing and said basically that he/she was going to far in terminating the resident. After this happened I am sure the PD was not cooperative with helping such a reinstated resident and basically just collected more "evidence" to boot the resident. So I am inclined to believe that the resident was, basically, setup to fail.

Most residents and attendings make a lot of errors in patient care, and there was a study showing how many potentially fatal errors *attendings* make over the course of a year, and it isn't zero . . . Medicine is very regimented where you don't have much of a voice in some programs in terms of honestly discussing your performance and you are expected to agree to whatever is being said (even if it is not clear to you or anyone else) and to pretend to work hard to "correct the problem". This part of reacting/understanding some bizarre criticism in medicine is just part of the game and is in a way a corrupted process where you are dammed if you do "agree" and dammed if you don't agree. . .

There is a double-secret probation sort of thing that you can use on people. I could even see how to do it though I wouldn't want as it is mean. I could single out an intern I don't like. Tell them that I have "concerns" about their bedside skills and ask to observe them more directly. And easily I could find something wrong, such as not checking more frequently if a patient needed a readjustment in pain medication or something like that. Tell them they need to change and discuss it with them telling them that "I think you can improve and we will see how the rotation goes". Then don't say anything for a long time, like a month or more, and check up on their patients behind their backs and make notes about *other* things that they did wrong (make a case for more generalized incompetence) and then spring it on them when I am sure at the end of the rotation I say that while they improved "marginally" in checking on patient's pain that they also say didn't do good discharge notes or other things (which perhaps none of the residents do perfectly well), and then give them a failure for the rotation and make them do it again and get more evidence when they repeat the rotation AND talk to other attendings to "be on the look out with this one."

In terms of cross-coverage I am sure I could nail 90% of residents to the wall in terms of picking through their work and finding something they weren't more cognizant with such and such a patient, it is bound to happen if you are cross-covering for 25 patients, got a bad sign-out and have to deal with urgent and pressing problems constantly.

While I wouldn't do this I am sure that plenty of attendings who basically complain a lot and are bored with their job would do something like this to a resident they wouldn't like. The sooner residents understand this the better as they can realize that they may not have done anything wrong BUT that they need to pretend to take it seriously and get away from the attending. Nothing is a better power trip than telling somebody else that they can't cut it as a doctor because it elevates the critique.

There should perhaps be things that residents could do to document what a PD does wrong in terms of their evaluation of residents, I would advise residents to keep a diary of what the PD says and why and what actions occur on a daily basis and especially if any PD or attending makes harsh or abusive comments to have a record of this to show later that some are too biased. If the OP had kept such a diary then they could have used it to defend themselves and might have scared the PD/attendings as they realize that this is a resident who crosses their t's and dots their i's and might have a better case than they do . . . A diary's ink can be tested to show how old it is and would be an excellent piece of evidence if done daily and well done over the course of a residency just in case something went wrong then at least there would be a record containing all criticism and from the residen't perspective how he/she fixed it.

(I know a resident, not in IM but in a highly respected field who did that and it saved her career literally when attendings were borderline harassing her and almost fired her, she documented what had happened and the hospital basically quietly forced the PD to keep her and have her evaluated by other attendings.)

Folks, you need documentation! The price of a medical education is pretty high and having a clinical diary with basically three sections is insurance that you can finish residency and takes only a couple minutes a day use a real diary and a real pen:

1. Abusive comments made by attendings, date, time and person.
2. Criticism, date, time and name of attending and service.
3. Your response to criticsm, i.e. changes made and viewpoint and whether the criticizing attending followed up.

Believe me, you are creating a legal document that backs you up, the PD and attendings are not nearly so thorough.

 

[satakay]

Thank you , d Neurology and southern IM, I swear the same thing happened to me..though I did nto like to go into more details. but you brough up this point and may someone else may benifit from it..
I admit that I belong to a Tribal society, and have never been exposed to such a complicated community..so there would be some social or linguistic parameters too..
the ist attending give me bad eval: was bc I did not give IVF bolus which she thought was septic...
I was on call and at around morning time a 76 yrs old pt was admitted wiht EF of around 30%, she was mildly septic and I didnt find any criteria for which I should hve given boluses and on top of that I thought it might complicate her conditions such as pulmonary edema and so on..so the morning team will decide about IVF..and started her on 150 ml/hr..
she took it against me and another thing happened at another day, that I did not calculated a GFR of a similar pt and gave him one dose of meropenem over night, while I should have given 500mg instead of a 1000.
but I admitted 13 pts that night from 5 pm to 6am..
Other than these mistakes, if any one could bring any of my mistake in pt care......
I promise..I will leave this country for good..

 

[satakay]

there is one more incident happened to me; where I should have been polite or clever, which I am not..
a pt was admitted to the Psych unit by an attending who has IM/PSYCH and the next chair of the department too..
so i was consulted for other medical issues HTN, DM, when i saw the pt.. the pt had all the signs and synptoms of Serotonin syndrome..I did an EKG and he also had a big QT prolongation..
I called my attending, and told him that the pt needs to be transfered to ICU or IMC atleast..but he was not agree and asked me to transfer the pt to the regualr floor..inspite of his order. I transfered the pt to IMC..and also called the other attending..he was also not agree and was thinkg the pt may be delerious..
anyway in the am rounds I asked my attending that this pt is sick and we shoud start rounds from there..but for sme reason he ignored my request..and when we reach this pt,s room..he was agitated and 6 people were holding him..so my attending even did not go inside and asked me to call the other attending who is med/psych..
I paged him mutltiple times to come urgently and see the pt..in the end he was mad at me and told me on phone that you have done your work and no need to page him again and again..
I documented all this incident and gave sign outs and left...
when I came nent day, in the am rounds my attending askig me..
do you know what happened to that pt?
I said yes..
I told you guys but you did not take me seriously and the pt died..and htis was infront of every body..
so he became very mad and started on me that you will be also sued and so on...
what happend was that the pt got deteriorated over that time..

and one more thing..the nurse calling the IM resident about the pt temp..from 39-41,42 ..and the on call resident order the nurse to call the psych resident..
during this time the patient obviously got coded and passed away..
Now that resident due to which negligence along with the attending are good but I suffered...
My plan and management is there and so is the others..lets take and see ..

Now the family of that patient has filled a Law suit..and I was telling every body that I will tell the truth if asked..

 

[DarthNeurology]

the ist attending give me bad eval: was bc I did not give IVF bolus which she thought was septic...
I was on call and at around morning time a 76 yrs old pt was admitted wiht EF of around 30%, she was mildly septic and I didnt find any criteria for which I should hve given boluses and on top of that I thought it might complicate her conditions such as pulmonary edema and so on..

Early management for septic shock is very important and saying a patient is "septic" is very imprecise. Did the patient have SIRS? Probably. Did the patient have hypotension OR was a known hypertensive and her blood pressure was significantly below her normal value, then the attending would have been (and probably was correct) about the fluid. If you had a hypotensive patient that you didn't bolus fluid and who was septic (hard to prove but hey if you've got a elderly patient with AMS and/or fever other SIRS criteria then you could say that she had sepsis as a lot of hospital patients do) . . . I admit your analysis is not great and your terminology is imprecise, perhaps this is because of it being a post but you seem a little too nonchalant about how you approached this situation whether or not the patient needed a bolus. Patients who an attending said should have gotten a bolus and don't get one this is a BIG mistake. Either a patient is intravascularly depleted or they are not, if they are then they do need fluids as septic shock is harder to correct the longer you wait, did the patient have a CVP or was in the ICU already?

http://www.survivingsepsis.org

 

[DarthNeurology]

and one more thing..the nurse calling the IM resident about the pt temp..from 39-41,42 ..and the on call resident order the nurse to call the psych resident..
during this time the patient obviously got coded and passed away..
Now that resident due to which negligence along with the attending are good but I suffered...
My plan and management is there and so is the others..lets take and see ..

Now the family of that patient has filled a Law suit..and I was telling every body that I will tell the truth if asked..

Teaching point is that if you find something amiss in medicine, be it a patient who needs higher level care, i.e. ICU and you go over somebody's head to get the patient to the ICU you OWN the case, even though you were more proactive you are on the ball and you must be super-proactive as you put the patient in the ICU and alerted everyone that the patient is more sick than they appear, never give yourself a pat on the back for "making a good pickup". Just the way it is, if the patient dies you will be blamed (mostly as a senior resident/fellow but also happens to interns). I don't know if you were involved with the high temperature, 107.6 = 42 so I am thinking that we are looking at perhaps neuroleptic malignant syndrome with psych patient? What was the CPK?

You were involved *critically* in the communication of the issues with this patient and you need to take a close look at yourself and see if you communicated everything properly and you should have gone out of your way to make the patient was evaluated *even* if the attendings initially ignored you as you are a doctor and your description of the event is too passive for an intern and WAY to passive for a pgy-2.

 

[satakay]

thanks a lot..as I said the pt did not puffil the cretiria and vitals were stabel at the time of admission..and usually the pts with theseptic pts wiht or without septic shock and SIRs admitted to the ICU in that hospital...
the only thing was changed from admission to the am rounds was the HR and temp, but BP was still stable..I admitt that I should have given boluses at least 500cc...
bc what happened during that day, they did give her boluses and she was transffered to ICU and was intubated bc of PE..

 

[DarthNeurology]

I paged him mutltiple times to come urgently and see the pt..in the end he was mad at me and told me on phone that you have done your work and no need to page him again and again..
I documented all this incident and gave sign outs and left...

This might be unacceptable, NEVER NEVER let anybody in the hospital absolve you of your patient care duties or concerns for a patient, if the attending tells you "not to worry" about a patient like this then you must logically that the attending has no idea what is going on. It is inappropriate to leave a patient like this and go home. Sorry, this may be different in the country where you are from but you have to take ownership and you can't just walk away even if your attendings tell you to, realize they may not have the whole picture. As the attending was mad the next day you must conclude that you did not properly descirbe the situation and did not properly inform the attending.

 

[satakay]

No it was the next on call team who was involved with the temp//
and the pt had Serotonin syndrome, due to clompromin and either codien or other anesthetics bc the pt had knee surgery couple of days before that..
and the admitting attendign was also concerned about the Clomipromin I dced..he told me on fone that the pt will go in rebound depression...and I told him..that I would rather see him go in rebound depression...

 

[DarthNeurology]

thanks a lot..as I said the pt did not puffil the cretiria and vitals were stabel at the time of admission..and usually the pts with theseptic pts wiht or without septic shock and SIRs admitted to the ICU in that hospital...
the only thing was changed from admission to the am rounds was the HR and temp, but BP was still stable..I admitt that I should have given boluses at least 500cc...
bc what happened during that day, they did give her boluses and she was transffered to ICU and was intubated bc of PE..

A good majority of patient fullfill the criteria for SIRS, they are pretty lenient and she probably did if she had tachycardia and a temp, BINGO, she should have gone to the ICU I guess if your hospital is proactive for sepsis PLUS if she was elderly and perhaps had symptoms of an infection like cough or a UTI then that helps too, also attendings may say that a patient "looks septic" and this is different than sepsis. Realize that blood pressure falls later on in volume depletion and the first sign is tachycardia, although if she had a PE that might be the cause there. It is not about just the vitals, did the history suggest poor fluid intake as well? Did her physical examination suggest volume depletion? There is a whole picture we are not getting. Because the patient did later get boluses she may have been dry or have intravascular depletion and realize that you may have missed the signs. Realize that if you missed the overall picture of the picture and if you quoted vital signs (which changed anyway) that it makes you sound arrogant and very unobservant in terms of evaluating patients and this is worst than not giving the bolus.

 

[satakay]

I was waiting tell 12 pm, then I had to sign out to the next team which I did, and told every body repeatedly that this pt is sick..and the floor attending to which servise I transffered the pt was there all the time..
My attending was not mad at my for the reason you said...
But he was mad bc I transffered the pt to his care..which the rifght thing I did..
He was saying that the other attending who is Med/psych has also preveliges in the medicine...
you should have transffered the pt to his care..which was wrong.
and then he was mad bc I told him infront of every body..that they were not taking me serious...

 

[DarthNeurology]

and the admitting attendign was also concerned about the Clomipromin I dced..he told me on fone that the pt will go in rebound depression...and I told him..that I would rather see him go in rebound depression...

The mental confusion and agitation with serotonin syndrome is different from "rebound depression" so your attending may have been mad at you because you perhaps did not describe the situation properly, i.e. in fact the patient had serotonin syndrome and acute agitation secondary to that i.e. being held down and any rebound depression is nonsensical and has nothing to do with a medical emergency. Your command of english may have been the problem, but realize that you may not have properly described the patient's condition over the phone and that if given time to intervene the patient's outcome may have been different.

It seems like you said "people did not take me seriously" and you said you paged people but they didn't believe you and the patient died. In these situations it is important that you DO make people take you seriously AND if people don't then you have to stay inside the hospital with the patient even though you are technically off-duty you failed your ethical and morale obligation to the patient if you knew they were seriously sick and left them in the hospital because "nobody would believe you." I can see why this would lead to somebody being fired.

It may not be your fault technically, but it just shows that you were preoccupied with being off call and didn't fullfill your duty to demand medical care for this patient. This may be because of a language barrier so may be you could improve your english as well as realize that what did will be perceived as not taking the care you provide patient's seriously enough. Honestly if you actually told them that you "weren't being taken seriously" this shows (or gives the appearance of not acting like an adult would or as being childish during a serious situation) that you realized that you had not communicated the problem properly and didn't care and went home. I would have been very, very concerned about this.

You may need to change your approach to patient care as without the attendings input it is hard to figure out what went on.

 

[DarthNeurology]

But he was mad bc I transffered the pt to his care..which the rifght thing I did..
He was saying that the other attending who is Med/psych has also preveliges in the medicine...
you should have transffered the pt to his care..which was wrong.
and then he was mad bc I told him infront of every body..that they were not taking me serious...

If your attending is mad that you transferred the patient incorrectly, i.e. to him rather than a Med/Psych person, then, well you are wrong in the attendings eyes and you can't say that you were right as I am sure the attending has a way of doing things and in previous posts you said you transferred patients to services against an attendings wishes.

Whether or not you are right is immaterial as the attending feel you did wrong. You should never contradict an attending in front of people, it demonstrates that you are "insurbordinate" and this can be as bad as poor clinical management. I am sorry if I misunderstood you, but realize that if you act childish and accuse people of not taking you seriously then they will question your ability to take care of patients in a calm manner whether or not this is true.

If as a physician you get a sense that somebody is not taking you seriously IT DOESN'T MATTER the buck stops with the M.D. you must make sure that everybody is taking you seriously. Say you tell a patient to ambulate after surgery and you know that "they aren't taking you seriously" and that they don't and get a PE, this is your fault as a physician as doctors must be clear and if somebody doesn't understand you had better make sure that they do. You must realize that the excuse that people don't take you seriously looks very bad, and could indicate that you don't care if people understand you or not OR that you don't take the time to make people understand you. NEVER use this excuse again it has no place in medicine and if you can't communicate clearly to people and make others understand you and take you seriously then you should so something else as this could happen again. No physician acting like an adult would use this excuse. I apologize for being blunt, but you don't seem to understand this concept.

 

[satakay]

Well thank you very much for your kind advise..
but let me clear one thing here..
1-the attending a paged was not my attending..he was technical on psych service..
2-My attending who was the floor attending whos responsibilty was to take over the pt form me..and did present, I did sign out to him..and he did the round on this pt too..
and he did write the note on this pt too..
he simply wanted me to call the other attending, which I did.. so let me say I didnt communicate well on the fone..but what about my floor attending who is responsible for this pt..and who was there all the time..

3- I would have been glad if they brought this issue and fired me for my negligence, lets assume..but no body ever brought this issue and never told me taht this was your mistake..
Rather taking a revenge some sort of..

 

[benjee]

there is one more incident happened to me; where I should have been polite or clever, which I am not..
a pt was admitted to the Psych unit by an attending who has IM/PSYCH and the next chair of the department too..
so i was consulted for other medical issues HTN, DM, when i saw the pt.. the pt had all the signs and synptoms of Serotonin syndrome..I did an EKG and he also had a big QT prolongation..
I called my attending, and told him that the pt needs to be transfered to ICU or IMC atleast..but he was not agree and asked me to transfer the pt to the regualr floor..inspite of his order. I transfered the pt to IMC..and also called the other attending..he was also not agree and was thinkg the pt may be delerious..
anyway in the am rounds I asked my attending that this pt is sick and we shoud start rounds from there..but for sme reason he ignored my request..and when we reach this pt,s room..he was agitated and 6 people were holding him..so my attending even did not go inside and asked me to call the other attending who is med/psych..
I paged him mutltiple times to come urgently and see the pt..in the end he was mad at me and told me on phone that you have done your work and no need to page him again and again..
I documented all this incident and gave sign outs and left...
when I came nent day, in the am rounds my attending askig me..
do you know what happened to that pt?
I said yes..
I told you guys but you did not take me seriously and the pt died..and htis was infront of every body..
so he became very mad and started on me that you will be also sued and so on...
what happend was that the pt got deteriorated over that time..

and one more thing..the nurse calling the IM resident about the pt temp..from 39-41,42 ..and the on call resident order the nurse to call the psych resident..
during this time the patient obviously got coded and passed away..
Now that resident due to which negligence along with the attending are good but I suffered...
My plan and management is there and so is the others..lets take and see ..

Now the family of that patient has filled a Law suit..and I was telling every body that I will tell the truth if asked..

sorry to interrupt. satakay, you said nobody take you seriously and others ignore you. When you reported to your attendings no matter which one ,Did you quote the clinical data eg. vitals,fever,clinicaly agitated or lethargic, delerious, tachypnea..etc?? If you did, did you ask those attendings why they keep that pt on the regular floor instead of upgrade the level of care?? I don't know what exactly the conversation, but I am sure if a pt is that sick , no attending wuld keep the pt on regular floor. What about the ortho team who did the surg to that pt???did they follow the pt??
Besides, admission more than 10 a night is alot if every single pts is that sick, Are there any cap?? probably not. In some ERs, the triage may not be appropriate, i means some pt belongs to ICU right from ER,n they should not be admittd to regular floor but they just want to get rid of pts, so you need to make sure pt is getting the appropriate care right from ER , means should they go to ICu or somewhere else...

 

[jigga]

Well thank you very much for your kind advise..
but let me clear one thing here..
1-the attending a paged was not my attending..he was technical on psych service..
2-My attending who was the floor attending whos responsibilty was to take over the pt form me..and did present, I did sign out to him..and he did the round on this pt too..
and he did write the note on this pt too..
he simply wanted me to call the other attending, which I did.. so let me say I didnt communicate well on the fone..but what about my floor attending who is responsible for this pt..and who was there all the time..

3- I would have been glad if they brought this issue and fired me for my negligence, lets assume..but no body ever brought this issue and never told me taht this was your mistake..
Rather taking a revenge some sort of..

I do not think so that negligence is the major factor which was held against you. Communication & interpersonal skills seem to be a major factor. Mistakes happen in medicine. And residents who are on good terms do tend to get away. I do not mean it in a degratory way as i strongly believe communication and interpersonal skills are quite important too. And you just cannot downplay the humilty aspect. A resident has to take the brunt even for mistakes not remotely related to him. And learning to stay calm and tackling such situations is as important as demonstrating clinical efficacy.

 

[jigga]

Now the family of that patient has filled a Law suit..and I was telling every body that I will tell the truth if asked..

I will never do that. And even if i have to i will not go on telling everybody. And if i am legally required to i will take a legal advice. And you were doing this at a program which according to you was targeting you. I do not think so PGY2 can afford to have a personality clash.

 

[jigga]

Dear Program director and other friends thanks a lot for your kind input..
I have tried a lot and have begged them not to destroy me this way, bc I have other serious issues going on, for example my family has trappend in the War zone, active war going on, almost 3 million people have been displaced so far..and I have to support my family here too, i have 2 kids..
I wont go in other details about their treatment, even at some point I thought they are treating me like a terrorist...
anyway I guess there is no point to think about these issues at this point..and I should move on as a stranger...
And let me say that all this was my fault and I am ready to comply with whatever way possible..which exam someone want me to go through..
but I suffered a lot for my career and would not like to loss it this way..

I was doing IM, and would of course like to continue in IM bc I already have almost three years of experience in it..
But I wont mind to go into other programs too..just to stay in this field..

I am ready to start it over.i.e from ist year IM...but the questiion is that who will take me and what will happen to the funding stuff..
is there any chance I can get back on track?
ANd how should I explain to othe PDs about my situations in case of any interview..

thank you very much

Apply widely and drop a cluster bomb application. You will need to communicate very effectively. Do not close your options. FM seems to be viable. So does PM&R. You have permanent residency which is a big plus.

I sympathize with you. But everyone has problems. Some may have worse problems. I will advise you not to play with the sympathy factor. You are not going to get a residency due to this and infact it might work against you.

The war zone thing you mentioned gave me a clue about your identity. I will never think that someone is thinking about me as a terrorist. If such a bias would have existed, then they got to see your picture at the time of application, they also got to see from where are you coming & they would have simply chosen not to call you. The majority of people do not fit the stereotype that is projected on news channels.

The only bias is at the airport screening. Lol.

 

[satakay]

Thank you very much friends, I am learning a lot of stuff from here and very thank full for kind suggestions and advise..
I would just go back and make it clear here about the stated case, that I presented the case on proper way both at night on fone and in the am, and then at bed side the intern did the same way...........OF COURSE I DIDNT SAY JUST LIKE THAT...(SIR THIS PT IS SERIOUS, YOU GOT TO PRESENT IT,)....and a 3rd year resident was there as well as the attending..
I briefly wrote about the case here and, I was assuming that you guys will assume that I presented the case as a resident..
And the attendign who admitted the pt to the psych unit, has never seen the patient, it was just on fone, and that was the reason I was calling him, to let him know about his pt..otherewise to manage thhe pt was our responsibility i,e IM team...

note all these things happened before I got into trouble..not after..

 

[Tigerz_Fan]

I am going to join in the conversation now...

Everyone here has presented good points that I think many reading this thread can learn from.

I totally agree with advice given so far:

1. During residency and any job for that matter, communication is key. Many problems that were presented here seem to have been due to a misunderstanding or lack of communication. And NEVER confront an attending or superior in front of the entire team. Always find a way to pull the person aside or discuss it at a later time.

2. Darth is on the money on this one. Even if an attending or superior does not feel that a higher level of care is necessary, if you feel it is so, DO IT. The person on the other end of the phone is not in the room with the patient and may not understand the entire story. Twice during my residency, I did exactly that. I transferred a patient to the ICU when an attending said not to. Both times, I initially caught hell during morning rounds until I mentioned that the patient had coded overnight (once arriving to the ICU). Regardless if you catch hell for it, you will have just saved a person's life.

Another rule of thumb: never leave, even post-call, if a patient is sick. Example: say no ICU bed is available, then what to do? Do you best to stablize the patient while waiting. Checking out a sick patient to the on-call team is unacceptable. You gave an example of admitting 13 patients overnight. The on-call team is too busy to admit, take care of cross-cover, and a patient like this. Only leave when no more can be done...

That being said, the resident taking call that night should have NEVER said to call the psych resident.

3. Now, no one mentioned this yet. I can understand why you were in trouble following the meropenem GFR dosing. This should be done on every patient, and double-checked if you are uncertain. This is expected of a PGY-2.

4. The septic patient brings up a few good points. Definitely refer to the surviving sepsis guidelines that Darth provided for you.

Sepsis aside, if you really were not concerned about sepsis, then a couple of things bother me about this patient. You mentioned an EF of 30%, and not giving her boluses due to pulm edema and such. But, you also mentioned a rate of 150/hr. That is a high rate for an EF of 30%, and not a typical maintenance IVF dose even for a normal EF. So, if normal vitals and such as you stated, why did you feel she needed such a high rate of fluids? Definitely be careful in the future on that one. The fact that she tolerated it leads me to my next point. You mentioned that she transferred to the ICU because of PE. Teaching point here: a PE is dependent on preload to maintain cardiac output.

5. aPD had very good advice. Go back to your PD and ask for constructive criticism. It can only help you for the future.

Okay, enough teaching. Good luck in your search. Don't give up, positions open up all the time. And I hope all is well with your family....

 

[michaelrack]

Sepsis aside, if you really were not concerned about sepsis, then a couple of things bother me about this patient. You mentioned an EF of 30%, and not giving her boluses due to pulm edema and such. But, you also mentioned a rate of 150/hr. That is a high rate for an EF of 30%, and not a typical maintenance IVF dose even for a normal EF. So, if normal vitals and such as you stated, why did you feel she needed such a high rate of fluids? ....

The OP's story is kind of confusing, but I believe he said it was the morning team that took over that gave ivf at 150 cc/hr

 

[satakay]

Thank you very so much all of you..
actually, whatever the situation was, I wont justify myself for it..bc I got my eval. from her missed up anyway and the things started from her onward and from the other case too....
But what I was trying to say, taht in the later case where, I think the patient was died from the Negligence of the morning team, bc they were the one who dced my management including sedation and IVF..and kept the pt on the floor till next morning untill he got coded..and even the nurse called the IM resedents and the attending saw the pt, yet no body took it serious..
And no body blamed me for it...But yet no body punished them either..
Lets assume that, I didnt do a good job..for whatever the reason was...for example communication issue, bad presentation and so on..
But my question is..that after every body saw the patient, examined the pateint, wrote notes on the patient, took over from me by the morning team...
So was I still supposed to sit there..though I stayed till 2 pm that day after a very bussy night..and tried to convence the 3rd resident to transfere the pt to the ICU..
so what else could I do in such scenario...
I got screwed up and the others not.......
I admit that I may be not an excellent resident, and would still need to fix my mistakes, but there are number of others worst than me..and they are enjoying their life..finishing theri residencies...
Still I would say keeping in view my situation......that I was the worst..
But what should I do now??
IS my career over?
or I still have some hopes?
and how can I explain my termination to others..for wahtever reason it was, but now I will have to cope with it..
thanks a lot once again and I really appreciate all of you..

 

[Tigerz_Fan]

Ok, it's a little clearer for me now.

So, you were night float when you admitted these patients, do I understand that correctly? If so, things make a little more sense...

Your career is NOT over. It may take time to get things back in order, but most importantly don't give up. Get on websites such as www.findaresident.com. As others stated before, be willing to move anywhere in the country. Definitely discuss with your former PD. And as far as explaining your termination, I honestly think that is a question best answered by aPD...

 

[satakay]

OH thanks a lot Tiger..finally ..
yes of course I was at night float..taht what I am trying to explain, and both of these cases I admitted aroung 1-5 am..

Thakns for the encouragement..
looking forward for more suggestion..

 

[benjee]

Thank you very so much all of you..
actually, whatever the situation was, I wont justify myself for it..bc I got my eval. from her missed up anyway and the things started from her onward and from the other case too....
But what I was trying to say, taht in the later case where, I think the patient was died from the Negligence of the morning team, bc they were the one who dced my management including sedation and IVF..and kept the pt on the floor till next morning untill he got coded..and even the nurse called the IM resedents and the attending saw the pt, yet no body took it serious..
And no body blamed me for it...But yet no body punished them either..
Lets assume that, I didnt do a good job..for whatever the reason was...for example communication issue, bad presentation and so on..
But my question is..that after every body saw the patient, examined the pateint, wrote notes on the patient, took over from me by the morning team...
So was I still supposed to sit there..though I stayed till 2 pm that day after a very bussy night..and tried to convence the 3rd resident to transfere the pt to the ICU..
so what else could I do in such scenario...
I got screwed up and the others not.......
I admit that I may be not an excellent resident, and would still need to fix my mistakes, but there are number of others worst than me..and they are enjoying their life..finishing theri residencies...
Still I would say keeping in view my situation......that I was the worst..
But what should I do now??
IS my career over?
or I still have some hopes?
and how can I explain my termination to others..for wahtever reason it was, but now I will have to cope with it..
thanks a lot once again and I really appreciate all of you..

Don't worry, that attending and the on call team will get their share , it's only depend on when cuz if the pt's family file a lawsuit after a death, everything will be under microscopic investigation. The most important maybe learn from any mistakes you made in the past and try to retain those good evaluations given by other attendings because those will be evidence/backup when you reapply and need explanation during interview process. It's going to be hard but still possible to get a second chance.Good luck

 

[eforest]

Thank you friends..I am a green card holder...and do not have visa issues..but I dont know about this funding stuff either..

And the criteria they held against me, was the only one ..for not being able ot meet the Director in first week of my remediatiion plan..otherwise they put me go through a huge load of work, to write many documents, meet three mentors and on top of that put in the bussiest rotations again, even the director denied to grant me one week for preparation of the shelt test, bc as you know I did my step-2 a while ago..but inspite of that I did well on that test..
They intended to kick me out what ever the reason was..either my fault or somebody else...but I am in hell now anway..and have no idea waht is going to happen to me..

At my school, medical students are not allowed time off to study for the shelf exams. To expect an entire week off to study for a test taken by medical students is a bit much. I find this part of the story really strange. I've never heard of a resident being made to take a shelf exam.

As for communication, do you have a thick accent? I do not mean to be insulting in any way, but there are a few foreign graduates who speak with such thick accents that it is hard to tell what they are saying.

 

[Speculatrix]

In general, residents who are struggling do poorly in their inpatient blocks and their continuity practice. Rarely do I see a struggling resident get a poor evaluation from an elective.

Umm, how do you do poorly in continuity clinic? I'm genuinely at a loss for how this could even happen. It's an afternoon a week on average, you draw basic labs for preventive maintenance and prescribe someone their hctz and statins... I mean, I would have thought this was the no brainer of the IM residency as opposed to the daily grind of inpatient wards.

 

[gutonc]

Umm, how do you do poorly in continuity clinic? I'm genuinely at a loss for how this could even happen. It's an afternoon a week on average, you draw basic labs for preventive maintenance and prescribe someone their hctz and statins... I mean, I would have thought this was the no brainer of the IM residency as opposed to the daily grind of inpatient wards.

You have much to learn grasshopper.

 

[adam6]

You have much to learn grasshopper.

👍👍

 

[Speculatrix]

You have much to learn grasshopper.

Why is continuity clinic so perilous? I genuinely found my family medicine rotation to be a whole lot less demanding than managing many complex issues in many hospitalized patients at once (i.e. on the wards). I know it's more than just prescribing statins and beta blockers, but I am truly interested to know why it can pose problems for residents to the extent that wards can.

 

[dragonfly99]

IM continuity clinic was one of the most onerous parts of my medicine residency. I was pretty much managing all of a patient's medical issues, in many cases without much input from any attending. Also, would get multiple patient calls and messages per day, often. All these phone calls and medication refills had to be dealt with by me. And this was in the midst of taking care of patients on the wards. The nurses on the floor don't stop paging you about stuff because you are in continuity clinic. And the families of your patients on the floor don't stop having the nurse page you to come see the patient and explain how he/she is doing that day. As an IM resident, YOU are responsible for taking care of all a patient's health care questions, all cancer and other health screenings, plus taking care of their chronic pain issues, often psych issues, high blood pressure, diabetes, heart problems, chronic lung disease, obesity, etc. It is definitely hard to kill somebody in clinic, but it's easy to miss a diagnosis of cancer, or to let the blood pressure go uncontrolled, because many patients are noncompliant and don't have much understanding about their own health.

Resident clinics tend to be very poorly staffed with ancillary staff such as nurses and med techs, so the residents often end up being the ones returning all the patient phone calls, etc. This can take a lot of time. Also, with our fragmented health care system, patients often appear having been treated @some OSH but without any records, etc. They also often come in with disability or family/medical leave paperwork, most of which falls on the primary care doc to fill out. This all sucks up the resident's time. Overall, it's a much different experience than my fellows' clinic that I have now...I would say I easily got 8-9 times the patient phone calls, etc. when I was doing primary care resident clinic.

 

[dragonfly99]

I actually don't think the patient care stuff described by the OP is that bad...there should have been an upper level resident there helping him/her in any case. It sounds like they needed a fall guy for the patient who died and he was it.

The OP does seem to have problems with writing in English, so the English speaking and communication was likely the primary issue. In general it's never good to confront an attending in front of other people...you will not win and it just makes them angry. It sounds like medically the OP was on track in terms of figuring out the patient was too sick for the floor, and likely what was going on medically...that's about all I would expect of an intern. It was the communication and politics that he failed at.

I agree that it is unusual to have an intern take a med student shelf exam, and it suggests they were worried about his knowledge base. However, assuming he passed the USMLE, and based on how he says he managed the patients above, I doubt his knowledge base is that awful. Maybe he'd benefit more from intensive English tutoring. Also, when there are problems with spelling, grammar, etc. in written notes, it makes the person seem like he may not know what he is doing...it makes him look either ignorant or uneducated. I'm not saying this to criticize too much, as I personally don't see how all these FMG's manage to pass the USMLE that isn't in their native language...I personally find it amazing and I think most of them must be really smart to be able to do so.

I agree with APD...it could be helpful to meet with the old PD. Have to be careful to be really polite, etc. The past is the past and nothing can change it. But it would be interesting to hear from his point of view, what he thinks the major 4-5 things are that the OP could do to improve. The OP may not agree with all of them, but likely something useful would be gained by hearing this. It requires the OP to swallow his pride yet again, but I thin it would be worth it, though might be hard to do. The OP needs to know the PD's point of view anyhow, to know what the PD is going to say to prospective new programs that the OP is going to apply to.

 

[Excelsius]

The thing that gives this resident some credibility is that he/she got kicked out of residency --appealed it however--, and then got back into the program!! There MUST have been some other attendings that looked at what the PD was doing and said basically that he/she was going to far in terminating the resident. After this happened I am sure the PD was not cooperative with helping such a reinstated resident and basically just collected more "evidence" to boot the resident. So I am inclined to believe that the resident was, basically, setup to fail.

Most residents and attendings make a lot of errors in patient care, and there was a study showing how many potentially fatal errors *attendings* make over the course of a year, and it isn't zero . . . Medicine is very regimented where you don't have much of a voice in some programs in terms of honestly discussing your performance and you are expected to agree to whatever is being said (even if it is not clear to you or anyone else) and to pretend to work hard to "correct the problem". This part of reacting/understanding some bizarre criticism in medicine is just part of the game and is in a way a corrupted process where you are dammed if you do "agree" and dammed if you don't agree. . .

There is a double-secret probation sort of thing that you can use on people. I could even see how to do it though I wouldn't want as it is mean. I could single out an intern I don't like. Tell them that I have "concerns" about their bedside skills and ask to observe them more directly. And easily I could find something wrong, such as not checking more frequently if a patient needed a readjustment in pain medication or something like that. Tell them they need to change and discuss it with them telling them that "I think you can improve and we will see how the rotation goes". Then don't say anything for a long time, like a month or more, and check up on their patients behind their backs and make notes about *other* things that they did wrong (make a case for more generalized incompetence) and then spring it on them when I am sure at the end of the rotation I say that while they improved "marginally" in checking on patient's pain that they also say didn't do good discharge notes or other things (which perhaps none of the residents do perfectly well), and then give them a failure for the rotation and make them do it again and get more evidence when they repeat the rotation AND talk to other attendings to "be on the look out with this one."

In terms of cross-coverage I am sure I could nail 90% of residents to the wall in terms of picking through their work and finding something they weren't more cognizant with such and such a patient, it is bound to happen if you are cross-covering for 25 patients, got a bad sign-out and have to deal with urgent and pressing problems constantly.

While I wouldn't do this I am sure that plenty of attendings who basically complain a lot and are bored with their job would do something like this to a resident they wouldn't like. The sooner residents understand this the better as they can realize that they may not have done anything wrong BUT that they need to pretend to take it seriously and get away from the attending. Nothing is a better power trip than telling somebody else that they can't cut it as a doctor because it elevates the critique.

There should perhaps be things that residents could do to document what a PD does wrong in terms of their evaluation of residents, I would advise residents to keep a diary of what the PD says and why and what actions occur on a daily basis and especially if any PD or attending makes harsh or abusive comments to have a record of this to show later that some are too biased. If the OP had kept such a diary then they could have used it to defend themselves and might have scared the PD/attendings as they realize that this is a resident who crosses their t's and dots their i's and might have a better case than they do . . . A diary's ink can be tested to show how old it is and would be an excellent piece of evidence if done daily and well done over the course of a residency just in case something went wrong then at least there would be a record containing all criticism and from the residen't perspective how he/she fixed it.

(I know a resident, not in IM but in a highly respected field who did that and it saved her career literally when attendings were borderline harassing her and almost fired her, she documented what had happened and the hospital basically quietly forced the PD to keep her and have her evaluated by other attendings.)

Folks, you need documentation! The price of a medical education is pretty high and having a clinical diary with basically three sections is insurance that you can finish residency and takes only a couple minutes a day use a real diary and a real pen:

1. Abusive comments made by attendings, date, time and person.
2. Criticism, date, time and name of attending and service.
3. Your response to criticsm, i.e. changes made and viewpoint and whether the criticizing attending followed up.

Believe me, you are creating a legal document that backs you up, the PD and attendings are not nearly so thorough.

A very informative post. Do you think that there is no value if the notes are taken in electronic format? I guess there could be a claim of faked dates, but if notes are taken often enough, it would be difficult to fake years worth of notes. Plus you can fake the age of ink as well - heat, UV, etc.


I too think that the problem here is the communication skills of the OP, but I still think that the majority of the responsibility belongs to the program. Given the importance of the communication and how it can result in a human death, the program should not accept anyone who cannot proficiently convey his thoughts in English. This can be ok in Ph.D. programs - though when the time comes to write the paper there are a lot of issues - but poor communication has no place in clinical medicine. It's not just the attending; what if the patient can't understand you or you can't understand the patient? Given the amount of material required to master in medical school, learning at least basic English communication skills is a far lesser challenge and can be achieved my anyone if a little time is devoted to this purpose, even while one is at the high school level (neither high school nor college teach much English beyond ESL).