What to do next all depends upon what Phase of Resident Decline that you find yourself in. So what are the four Phases of Resident Decline you ask?
Phase 0- All is well in residency land. You are working hard, getting the concepts, and the patients are being taken care of. Ideally, this is the place that every resident starts. Your goal, if you happen to be in this stage right now, is to stay in phase 0 for the duration of your residency training. The book Staying Human During Residency Training: How to Survive and Thrive after Medical School is chock full of excellent advice for how to stay here. I wish that I had taken the time to read this book before I started residency. But... the fact that you are visiting my website typically suggests that you have probably found yourself somewhere between phase 1 and 4
What Do I Do Now?
Phase 1- There have been mistakes, misunderstandings, or miscommunications that have started to generate friction between you and your faculty, or you and your senior residents. You are starting to get an uncomfortable amount of attention, and maybe you have even been counseled formally, or informally once or twice. Phase 1 is the best place to take a huge step back, evaluate the patterns that appear to be developing, and take drastic steps to correct them. Based on the known psychological/psychiatric effects of prolonged periods of sleep deprivation and elevated stress levels, this is also a good time to seek out an evaluation from a psychiatrist/psychologist. Seeking help further down the line, after more damage has been done, may help explain difficulties, and will most likely promote improved performance. But, getting help too late can still allow irreversible damage to occur. This is what happened in my situation, I was altered, and someone figured it out almost a year into a steady psychiatric decline, but by the time this happened, my program director and faculty had run out of patience. Even if you cannot see a psychologist/psychiatrist immediately, there are some quick changes that you can make to improve your performance. Most likely fatigue, and a less-than-ideal diet, are contributing to a reduction of, or complete absence of mental focus that allowed you get to this point. Chapter 2 of Staying Human says the following:
“Top 10 Cognitive and Neurobehavioral Effects of Fatigue: 1) Alertness and vigilance become unstable; lapses of attention increase. 2) Cognitive slowing occurs; time pressure increases errors. 3) Working memory declines 4) Tasks may be begun well, but performance deteriorates with increasing rapidity. 5) Perseveration on ineffective solutions increases. 6) Neglect of activities judged to be nonsensical (loss of situational awareness) grows. 7) Involuntary microsleep attacks occur 8) Increased compensatory effort required to remain effective 9) Risks of critical errors and accidents increase. 10) Cognitive deficits can be masked by stimulation.”
Resist the impulse to get a prescription of adderall or any similar stimulants. Yes, these can work wonders in the short term, but there can come a time when your receptors have been up-regulated and you are right back in the same place. Except now you also have some substance issues. Some of you may get prescribed Adderall and do fine. I am just putting a warning out there, because I am not the only person that I've seen crash and burn on this medication during residency training.
“Depression and anxiety symptoms were reported to be 3-4 times more common in a sample of family medicine residents compared with the general public.”
“40 percent of residents reported impaired performance as a result of anxiety and depression lasting 4 weeks or longer.”
- Chapter 1 Staying Human
Phase 1 of the residency struggle is the ideal time to seek out some behavioral health assistance. There is a chance that for the time being, you can benefit from antidepressant medication. You should also optimize your diet, sleep, and exercise habits during this time. Easier said than done.
Phase 2 - You have been placed on Academic Probation/Hospital Probation. There are two reasons why they might have done this. The first reason would be that they are trying to get your attention and improve your performance. If this is the case, the probation document will have some very specific goals, objectives and standards. There should also be a performance improvement plan, specific mentoring, assignments, or tasks meant to bring your performance up to the standards described in the document. The other reason for the probation is not as noble. They need to place you on probation in order to terminate you, it's pretty much required by the ACGME. If your probation document lacks the specifics that I mentioned above, and seems to list vague complaints and nebulous/impossible standards, then there is a high probability that your probation is simply a checkpoint on the highway to termination town. If you have even the slightest suspicion that your probation is intended to move you closer to termination, then I would highly recommend consulting an attorney. At the majority of the GME committee hearings, the resident has to speak for him or herself, but the attorney can still help you identify violations and irregularities which my strengthen your presentation. In general, I would only recommend contesting the probation if you have issues with the way that it is written. If your program director has requested that you be placed on probation, you can be pretty sure that the GMEC will approve the request. Requesting a hearing to discuss the matter will most likely irritate your program director, so take that into account before you decide how you will proceed. If you think something shady, or suspicious is going on, this is the time to hire a lawyer, request a hearing and point out the vague, poorly defined terms in the probation document which will clear the way for a swift termination if you 'fail' to meet the standards. Something important to keep in mind during this phase is the relationship between you, the staff, and your fellow residents. According to the book Getting Cut: Failing to Survive Surgical Residency Training, "35% of terminated residents cited personality conflicts as the reason for poor performance." additionally, "even faculty members agree that sometimes bad feelings result in bad evaluations that are not accurate reflection of a resident's abilities." My perception is that this was the case in my situation. Be very mindful of your interactions with staff members and make a strong effort at keeping conflict and friction to a minimum. And yes, the field of Medicine and surgery specifically, is a white male dominated profession. This does mean that a certain amount of in group protection is going to occur. This means that in general, you may notice a trend of different treatment or different performance standards for you if you are a female or a minority. From Getting Cut:
"About three out of every one hundred residents who begin their surgical residency training were fired before completing their programs. Just as we found for resignations, however, this rate varies based on the resident's race and gender. While overall risk three percent, the risk for white females, however, was five percent, for non-white males was 20%, and for non-white females, it was 23%. Therefore, white females were 2.5 times more likely to be terminated than white males, while non-white males were 8.74 times more likely, and non-white females were 9.87 times more likely."
That sounds like racism or discrimination, and in my opinion, it is. But sadly, most white people don't see it that way, and don't care. Launching an equal opportunity complaint at this point is VERY likely to elevate whatever conflict that already exists between you and the involved parties.
Phase 3 - The probation progressed directly to a termination. However, you have not been terminated yet, you are awaiting your hearing, and at the very least, you have conducted a brief internet search of options and strategies. Chances are, this is what brought you to residencyrehab.com. This is a difficult position to get out of. In most hospitals that I know of, residencies must get all terminations approved by the hospital Graduate Medical Education Committee (GMEC). Unfortunately, the GMEC is often made up of friends and peers to your residency program director. Additionally, they are attending physicians, who approach your termination with an attending's perspective. More often than not, this means getting rid of 'dead weight' or difficult residents. If you were to 'succeed' and somehow defeat the termination attempt, you must understand that you will be headed straight back into the lion's den to complete (or attempt to anyway) your residency. Tread lightly when you are given the opportunity to speak at the hearing. Leveling accusations of gender and race discrimination will most likely be poorly received regardless of how accurate they may be. Physicians do not appreciate being called racist or sexist and you will inflame the situation and turn some people against you. The core of your defense must be based on your proven competence, and the evidence that supports this. Studies have shown that perceptions of a resident being unteachable often lead to termination, so you must not display an attitude of defiance or hostility as you present your side. If you plan to file a lawsuit someday, or think that you might, then you want to push forward with this hearing. For the most part, resignation hinders your ability to level litigation against the residency program. If you believe that you have been treated fairly, and that the residency has made a solid attempt to rehabilitate you, then you should strongly consider resigning and looking into other specialties.
Phase 4 - You've resigned or been terminated from residency. This is the hardest phase to deal with, and the one that causes the most anxiety, frustration, anger, and lust for vengeance. Take a deep breath and read on.
Active Duty Military
As an active duty military resident facing a tough situation, you do not have the freedom to resign and quickly apply to another residency the way that a civilian might. But with that limitation comes a vast safety net. After I was terminated I was transferred to a primary care clinic and underwent a 90 day period of evaluation. When I was deemed 'qualified' to treat basic primary care issues as a General Medical Officer I was free to take assignments around the military as a unit primary care provider. I spent a total of 9 months in a 12 month period in an administrative hold position or on a medical leave of absence. I continued to receive my normal salary during this time period (roughly $100K annually). So although you are more constrained and have fewer options in the military system, you will at least be able to pay the bills. Every September you have the chance to re-apply to residency. Of course, the people who kicked you out in the first place will probably be at the table when they make the decision in December, so you will have to strongly consider a change in specialties. (No, I did not taking my own advice on this).
You can spend years as a GMO getting great evaluations and developing a reputation as a strong, competent physician. When the time comes, you will be more experienced, more mature, and most likely a more attractive selection for many of the military residency programs.
Discussions with a civilian clients made me aware of a very difficult situation for non-military residents facing termination. After termination or resignation, you will most likely be unable to work in the specialty that you trained in since you have not yet finished residency and are not board eligible. Despite hitting this major road block, you must finish residency to optimize your earning potential and to advance in your career. If you get terminated before the end of your PGY-1 year then you will probably want to consider re-entering the match. If you make it to the end of your PGY-1 year, then you should be qualified to apply for PGY-2 and above positions in the specialty that you've been training in. Moving to a new residency position in the PGY3 or PGY4 years can become very difficult. For the most part, you have to wait until a position opens or is vacated (check the AMA Page, Residency Swap, FindAResident or the Association of Program Directors in Surgery), and then you apply directly to the department with a CV, written statement, and letters of recommendation. A good way to find out where some available positions might be is to look at the Match Results (2013 ). I have highlighted the column that indicates the number of unfilled positions for each specialty. Click here for detailed match results on the NRMP website. This can be a good place to find programs with unfilled positions in the past.
After you have applied to a new residency, the first thing that every program director wants to know is "Why did you leave your last residency?" You can count on them calling your previous program director to find out. Depending on what kind of wake you left in your trail, this can be the step that costs you that new residency position time and again. Two of the former residents I've spoken with have taken their residency programs to court to force them to reverse terminations, to limit what they are permitted to say about them, or to force a letter of recommendation out of the Program Director. In both cases these concessions have not yet led to them returning to training (2 years for one, 9 months for the other). So, what if you can't get back into residency immediately, you have no income, and still have to deal with living expenses, loans, and accumulating interest? If you have pursued legal action, you are starting to realize that the proceedings will carry on for years into the future. For every month that you are not working, the gap on your CV grows larger and your clinical skills deteriorate. What do you do now?
Most states require you to pass all three steps of your board exams and successfully complete your intern year to be granted an unrestricted license. If you are an EFMG, states can require an additional 2-3 years of stateside practice in addition to the intern requirement. Even if you have a valid license and two or three years of residency training, without graduating, you may find it difficult get hired. It could also be difficult to get credentialed and compensated by medical insurance companies. But I do have an associate who left residency in lieu of termination in the R3 year of a 5 year surgical program. He has been making very good money at a local urgent care. If you are from a specialty that is not ideal for work in an urgent care, I would suggest that you do your best to quickly bring your skills up to speed through shadowing/volunteer work, or something like that. From what I have seen in the 1.5 years that I've been running this site, urgent care centers seem to be your best bet for paying the bills while you look for a new residency.
As far as taking legal action is concerned.. approach this option with caution. Based on my research, you can expect a lawsuit to take several years (5-10) before it concludes. If you review the list of lawsuits you will find that 3 of 40 achieved a victory with a monetary pay out. So basically, it is very likely that you will wait a long time, and you will be disappointed in the end.
Focus your energy on getting to that next residency. If you have an abundance of evidence to support your claims of unfair treatment, and you feel confident after reading through the cases, then by all means seek out that next residency AND sue your former residency program.
RUNNING OUT OF OPTIONS
So, there are a few of you out there who might find that your evaluations and the timing of your termination make it nearly impossible to work or pursue that second chance at residency. In these cases, the best option for you might be an Observership. This is something that I very recently became aware of. They are marketed as residency preparation experiences, and just like the 3rd and 4th years of medical school, they cost you money. But.. they can allow you to get a new set of evaluations as well as letters of recommendation that could allow you to move forward with a new application. I've placed links to a few different programs below.
University of Nebraska Internal Medicine
University of Pennsylvania
As I continue to scour the internet for solutions of my own, I continue to learn of more approaches to the issue of re-entering residency training. According to some sources, the observership is more appropriate for the Foreign Medical Graduates who are most interested in fine tuning their language skills and adjusting the U.S. hospital environment. If you are short on options, looking into Observerships or Externships (similar idea, but in a private clinical setting) might be to your benefit.
Another option that I recently discovered is Non-GME training. These are training and career advancement opportunities that do not grant you ACGME credit, but allow you to practice medicine in a trianing environment. Might be the perfect bridge between one residency and the next. I've placed a few links to hospitals and departments that offer this opportunity.
NIH Clinical and Translational (Non-ACGME) Programs
Policy on Oversight of Non-ACGME Accredited Training Programs at the University of Arizona
The most promising option that I have come across so far is AmeriClerkships.org. I found the page by typing 're-entering residency after termination' into the google machine. Coaching residents through the steps to get back to a residency after being terminated something that they claim to specialize in. As with most of these options, I have no idea how good they are. They are kind enough to provide some honest feedback from their past clients. A common complaint is the amount of money that they charge for the services provided. I'm guessing that they are at least as expensive as a semester of medical school. Another interesting note is that their main service appears to be getting IMGs set up for the match and residency training in the United States. I don't think they will be much assistance to me given that I am currently practicing medicine in an urgent care and am simply trying to gain access to a competitive residency program. However, those of you who need to get back into the game through any means possible, this might be the option for you.
I have also had a former intern contact me in recent months (mid 2018) who was terminated from her residency during her intern year. As I have said before, this particular scenario can be the most disastrous of all. It leaves you without the ability to get a license, no letters of recommendation to get a new internship through the match, no ability to work as a physician, and very limited options for moving forward. She was able to find a community hospital in rural North Dakota that allowed her to volunteer and to be mentored by staff in one of their clinics. They then wrote her letters of recommendation after her time with them was completed. She used those letters to enter the match, and was able to get several interviews.
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