QUOTED: Desperately need to finish residency

[NotAProgDirector]

I had recently been terminated from an osteopathic residency program and need advice as to what steps to take to get into another program.

Since being terminated, I had been trying to contact multiple osteopathic programs via email of which some have gotten back to me. I have already sent out multiple CV's, personal statements that tell why I was terminated, letters of recs from other physicians, and references from them as well.

One of my past attendings who has given me great evaluations and is writing an LOR for me suggested I contact the hospital where she trained at, however it is an allopathic program. What are the requirements for that if I had already completed internship year at an osteopathic hospital?

In the meantime I have been trying to look for a job. I am already DEA and state licensed, however I believe I need to be a resident for most moonlighting positions & all others require I be board certified in IM, FP, etc etc. I have been trying to find a job that would be worth the income considering I have at least 1K a month in school loans alone that are starting to demand payment since being terminated. However most other jobs/ careers not dealing with health care that would pay enough to be worth it considering how much I owe in loans have other professional requirements that I don't have since I dedicated the 1/3 my life (the past 10 years) to getting into and studying medicine. Working at the local Starbucks would make me just enough to pay my loans. To make things worse, our only income now is my wife who is working 7 days a week now to pay our mortgage on our new condo that we just bought (being terminated was unexpected in our plans) while I am unemployed and trying to find another residency where I can finish at.

I am desperate to the point of actually standing on intersections near major hospitals with my white coat and a big cardboard sign saying I am DEA licensed and Certified and will offer medical care for food or money!!!

So what steps should I take? How can I get back into a residency? Know of any programs I should try? I am willing to go anywhere in the country.

First of all, I certainly feel for you. You don't need me to tell you that you are in a tough position.

There are no easy answers to your questions.

What can you do now that you have been terminated?
This begs the question of why you have been terminated. Residents can be terminated for several reasons but usually one of three: 1) Lack of clinical competence -- i.e. inability to perform the necessary duties of being a physician; 2) Professional violation -- sleeping with a patient, getting in a fistfight with security over a parking spot, etc; 3) Drug abuse (usually recurrent). Regardless, the process is the same:

1. Contact programs, as many as possible given your personal situation. Given your family moving across the country may not be an option, but you may need to be flexible.
2. Use contacts -- this is one of the best ways to find a new program. If possible, your best contact is your previous PD. I realize that in some / many situations this may not be feasible. In that case, having faculty advocates speak for you, make calls for you, etc may make all the difference.
3. Be as open and honest about the issue as possible. Most PD's don't want to hear that you were judged unfairly, etc. That's simply because it usually isn't true. Although I certainly admit that there must be some residents who are judged unfairly, some terminated residents who feel so have poor insight into their problems, and that's a HUGE problem for a new PD.
4. If you are looking at allopathic programs, then FM and pathology are the least competitive and are worth looking at if you are interested. If you don't know which programs to start with, start looking at last year's match lists posted here.

What credit will I get in an allopathic program for my osteopathic training?

The answer usually depends upon the specific board. However, you should assume that the answer is: none. In IM, zero credit is given unless your home osteopathic program also houses an allopathic IM program or the program is dual accredited.

What else can you do with your training if not continued?
If this is the road you plan to follow, you will need to be creative. Some "walk in clinics" hire docs who are licensable but not necessarily board certified. Most insurance companies only allow board eligible docs to register with them, so this is a big problem. You can't be a PA without going to PA school (there's a whole thread here on SDN about that, you can search for it), same with nursing. It used to be possible to go into industry (pharmaceuticals, etc) but that is now much more difficult without full training. There are threada about this topic also, without any easy answers.

The short advice is to try to finish your training now if possible -- that will open many more doors to you in the future. Use any resources you have. Have faculty make calls for you -- a call from a faculty member means much more to me than a random call/email from a resident.

Good Luck!

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[NotAProgDirector]

Well the reason for being dismissed according to my dismissal letter is 1) lack of clinical competence and 2) they claimed I lacked integrity.

However all my evaluations and attendings state otherwise... and I have them as references and letters of rec to vouch for that.

From what I have gathered, it sounds as if my PD based opinion of lack of integrity based on what a few other residents (who are close to the PD) have said behind my back... then tried to find any specific situation to get me terminated. Furthermore it was only one big stupid mistake on my part that the PD made to sound more like an issue of lack of integrity and incompetence.

I don't know if I could contact my PD about referring me elsewhere, I have seen how this PD deals with people that get on the PD's badlist. The PD could make a person sound so bad that I have seen an attending get asked/ forced to quit because of the PD... and it wasn't the attending's fault, but the fault of other residents talking to the PD behind the attending's back and making outrageous claims.

I have my attendings to vouch for me, I tell other PD's the whole story, make my dismissal letter available to them, and have no problem with them contacting my PD... but who else can I get to vouch for me?

Like I said, I am willing to go to other states to finish FP... and my spouse is ok with me leaving for a year. But if I don't get into anything else, I don't know what else is left for me to do.

You seem to have a reasonable grasp of the situation.

A PD is going to wonder whether you're in denial of the problem at hand. I have had to terminate my fair share of residents, and it is the worst part of my career as I realize that I put them in a difficult place. It stresses how important it is for me to choose residents who are very likely to succeed in my program.

Most of the residents I have terminated have left on good terms. A few have not, and their story is always the same:

1) They have lots of good evaluations, and they don't understand what the problem is. The fact of the matter is that most residents who are terminated have many good evaluations, and then a small collection of concerning ones. I stress to them that the minimum acceptable performance is all satisfactory. There is also the problem of grade inflation -- if you are scored on a 1-5 scale with 1 being unsatsifactory, a score of 2 looks fine but may in fact be a serious problem (the same may be true of scores of 3)

2) They feel there was only one error that led to their termination -- although I cannot speak for others, I expect that most residents are terminated for a pattern of poor decision making. Terminating a resident is a huge nightmare, and PD's won't do it simply for a single mistake. There can be a sentinel event which triggers the termination, and residents equate that event with their termination.

However, as a profession we are not good at giving residents feedback on their performance. If a resident's performance is marginal, this needs to be stated clearly. I used to try to "soften the blow" as much as possible -- now I'm very clear with residents that are struggling that they need to improve their performance, and that it is their responsibility to do so and my responsibility to help them succeed.

3) They feel there was a conspiracy. Sometimes it's random, sometimes based on some demographic factor (race, age, etc).

As you can see, your story mostly fits these three criteria, which makes me worry that there may be a real problem that you are not admitting to. "Lack of integrity" often equals difficulty with the truth, which is also a red flag. That being said, it's also possible that your PD is a jerk. Or both.

Anyway, looking forward, your best options are:

1. Start the conversation with being willing to repeat your PGY-2. Yes, this is painful but it's probably what you need to do. Perhaps your program will promote you to the PGY-3 level after a few months, but it's unlikely anyone will take you at the PGY-3 level having been terminated at that same level.

2. If you have friends on the faculty, have them call PD's on your behalf.

These are probably the best options, short of trying to start your training all over again in an allopathic program, which is an uphill battle of a different sort for many reasons. You will need to contact programs regularly, as spots may open at different times. It will be a long and frustrating process, but with hard work you can probably be successful. As mentioned before, your other options are very limited.

 

[Doodledog]

See below

1) As far as my evaluations go, they have been pretty good, I get evaulated in different areas of each rotation with a score of 1-5 and I get mostly 4 and 5 with positive comments. There is one eval I am worried about, it was on a IM specialty rotation where the attending verbally gave me comments like, "best resident I have ever had", "excellent diagnositic skills", "if I where IM he would recommend I go into his specialty"... but he was an attending that never got his evals done quickly. When this all went down, I went into his office to ask for some help and advice regarding my situation, he thought I came in to ask if I could moonlight, turns out that he was also part of the commitee (I forgot), and after speaking with the DME he said there isn't anything he can do to help me. After being terminated, I asked if I could ever get a letter from him, he said it won't be the best letter considering what happened... I just wonder if that ever affected my evaulation as well. However, I got a number of other attendings to write letters & vouch for me at the commitee meeting regarding my termination, but it was not enough.

2) After talking with friends at other programs that happen to be chiefs at there programs, they all told me the same thing, they have had much worse residents than me that truly deserved to get terminated... and it took months of documentation and lawyers to get them terminated... which my program did not have, but me being a poor resident, I can't get a lawyer to fight for me... besides I don't want to bring litigation into this.

3) I don't feel that there is a conspiracy... however there have been numerous cases before me that I know of where students and attendings that have fallen out of favor with this PD and have suffered similar consequences.

Back on topic...


Like I said, I have no problem starting as a PGY2... if anything, this has made me much more determined to finish up and be the best resident I can be.

I have actually gotten a number of job offers this past week for urgent care & locum tenens... in fact I am already on the schedule. However this past incident that got me terminated has been such a big blow to my confidence as a physician. Honestly I am scared and apprehensive about working completely on my own, but I have to... I have medschool loans to pay, a mortgage to pay, bills... I have to work!!!

So what I don't understand is this... I am crying out for help!!! for any residency program to reach out and help me through this so I can finish my residency, regain my confidence, and learn from my mistakes with supervision so I never do it again... to help me be the best physician I can be. Instead I am just tossed out on my own, to make a living, which I am scared for myself and my patients... wouldn't the lesser evil be for a residency program to take me in?

here is an interesting article I found that relates what I am going through... except I guess I am the most extreme example of this:
http://www.stmarymedicalcenter.org/...=www.stmarymedicalcenter.org&searchId=5002618

 

[anonymousperson]

I wanted to respond anonymously.

First, let me say that part of what aProgDirector says is true and part is not IMHO. It is absolutely true that there is generally a pattern of behavior that leads to dismissal and that this may not be recognized specifically by the individual. In other words you may not be specifically told when each event occurs. Likewise, I do not believe that residencies conspire to terminate residents based on demographics such as race/religion/gender. It would be far easier and more difficult to prove for them to just not rank you in the first place.

However I disagree with the remainder of his statements and again, this is simply my opinion. Program Directors most certainly can exert influence on attending staff and I have seen situations where attending staffs who have positive views of people changed them abruptly to uniformly negative when the Program Director wanted to terminate a resident. I do not claim to be party to the behind-the-scenes action so I cannot say why this was the case, only that it was observed by the entire residency staff. In this manner I would agree with you that there is a definite conspiracy, although not based on the above characteristics, in order to oust residents. I do not say this to malign aProgDirector, who is trying to be helpful, but only to say that his portrayal of a firing always being justified and perfectly the fault of the resident is not entirely accurate.

It is undoubtable however that you will have to state that you were completely and totally at fault. It may be fact that this was the case, it may be fiction. However, Program Directors are a fraternity and they may dislike some of their colleagues or have reservations about them privately but they will never allow an outsider such as yourself to cast doubt on the judgement of their peer. I have seen residents be fired and I have seen residents try to overcome this obstacle and this is the basis of my statements.

 

[NotAProgDirector]

I appreciate the debate.

I would like to believe that Program Directors have their resident's best interests in mind, and act as advocates for them. I would like to believe that PD's would not simply terminate residents for a medical error, as most errors are at least partially due to systems problems.

I am sure there are some poor program directors out there, who can be vindictive, capricious, and malignant. This is truly distressing to me, and I can think of no greater crime in GME than terminating a resident without good cause -- as the OP's story evolves, it is clear how devastating that could be.

I would also like to believe that, despite my avatar, the proportion of evil PD's is low. I have absolutely no data on which to base this belief. I worry that they may be concentrated in programs with the "most vulnerable" residents -- IMG heavy programs, with many residents on visas. Termination would also result in revokation of the visa, and hence the resident would have little time and/or options to address.

In my original answer, I had assumed that the termination was warranted. I could certainly be wrong about that. Residents should not be terminated for a single medical error -- unless it involves a professional issue also (ie leaving while on call to go to a party). If there is a pattern of multiple errors without a clear attempt at improvement, that's a different story.

When evaluating a resident who has been released from a previous program where there is a difference of opinion between the PD and the resident, it is often impossible from the outside to figure out what really happened. Realistically, if you tell me that you were fired for no good reason and the PD tells me that you are incompetent, how am I supposed to figure out where the truth lies? There really isn't any way to do so reliably, and so many PD's will not accept such a resident not because of a "fraternity" but because there's no way to tell who is telling the "truth".

On the subject of medical errors:
I personally was involved with a direct patient death from a medical error as an intern. It was horrible, and it is not a good way to learn medicine. What's interesting about the story linked above is that there is no control rate -- what percentage of trained physicians are involved with a medical error? In the last decade, I know of at least three patients which I was directly involved in their death, either by missed diagnosis or a mistake in clinical care. Presumably, there are a bunch of cases where I never found out I missed something (most studies suggest this is at least 3-5 times higher), and if you include other serious outcomes other than death (i.e. renal failure, etc) the number will be much higher. This problem does not stop after training.