(note that this is not legal advice, but may make you aware of some of your options.)
We continue to attempt to identify the processes for reporting violations, complaints, disruptive behavior, etc. Those will be added as they are identified. Additionally, we anticipate being able to add information about organizations and individuals who can offer support. If you can add a helpful link, resource, or pertinent information, please share with us so that we may add it here for others’ benefit. In the meantime, if you find yourself in significant distress or need immediate support, seek out your organization’s counseling office for help. If your program is academic, you may find assistance at your Department of Student Affairs. You should have access to a resident ombudsperson through the Office of Graduate Medical Education or your Designated Institutional Official (DIO). Additionally, your hospitals and medical school should have online links to confidentially report adverse events, violations, and disruptive behavior.
Talk to a faculty member that you trust, perhaps one from outside of your department. Speak confidentially to other residents that you believe could find themselves in a similar situation. There may be a Resident Association at your university or program that may be able to assist to some degree with resident grievances regarding the fair application of GME policies. All along the way, take great care to document: dates, meetings, conversations, emails, witnesses. Download your emails, evals, duty hours, test results and other important information onto files outside of your institution so that if you lose access along the way, you will have these valuable data in your possession. Know what is being put in your evaluations and resident file. Draft objective and thoughtful rebuttals to items with which you disagree and submit them to your residency coordinator to be placed in your file. Talk to support staff, medical students, residents and attendings from other services, and even patients, with whom you have had positive interactions and ask them for an email evaluation. (Here’s an example.) The ACGME requires your program to review a broad range of multidisciplinary evaluation sources about you.
There are complaint outlets outside of the residency program and medical school, as well. Again, hospitals are responsible for monitoring disruptive physician behavior and should be very interested in the topic for reasons of litigation liability and patient care/satisfaction. Hospital medical staff services should have a reporting mechanism in place. Additionally, disruptive behavior should be reportable via hospital quality improvement/assurance mechanisms (if in doubt, ask a nurse manager which system the nurses use for adverse patient care events, like falls and medication errors).
Outside of the hospital setting, state medical licensing boards should have reporting processes in place for disruptive physician behavior. The ACGME has an ombudsperson and official complaint processes in place for residency concerns/violations. Know that the ACGME will not assist in individual cases. It is looking for “patterns.” Of course, given the confidential nature that individual residents should be granted, that confidentiality acts as an insulation such that you are unlikely to have good information on broader issues within your program. This is a fatal flaw in the ACGME’s complaint and investigation systems. They will not help you individually,… and you do not have access to anonymized complaints or survey results in order to prove a pattern. An almost impossible situation, unless you band together with fellow residents, which creates its own high-risk situation for you.
Research avenues with other agencies: the AMA, The Joint Commission, Medicare, specialty boards,… Ultimately, none of this substitutes for legal counsel or action, and it may require litigation to force transparency and compliance upon sclerotic systems. This can be time consuming and expensive, which makes it especially difficult for residents who may be working more than 80 hours per week and have little disposable income from their residency stipends. To make matters more difficult, physician residents seem to fall into a worker sub-class: not really covered by employment law, although they are primarily workers rather than students; and disadvantaged for their association with universities – as courts appear hesitant to intervene into matters of education and professional credentialing. It’s a no-man’s-land where residents can be treated as indentured servants without adequate protection of human rights. Residency programs can be very accepting of your excessive labor, but when a work or evaluation issue arises, the university hierarchy puts up its shield: “These are educational proceedings, not legal ones.” Finding an attorney with experience in these matters can be a challenge. Also note that if you have not followed all of the prescribed institutional processes for grievance and appeal, it is highly unlikely that a court will intervene. Find and follow those procedures and processes as outlined by your GME office. Know those processes well. Make sure that you follow them, and demand that the institution do the same. These processes are often time limited to a matter of weeks, so do not delay. Also consider collecting communications, making a list of witnesses to events, compiling irregularities and defenses, and generally creating documentation in the event that you need to make your case in an appeals setting, or eventually in a courtroom.
Fear of retaliation and termination are particularly strong disincentives for heavily indebted residents who cannot readily match into another residency program or overcome the retaliatory letters of recommendation from program directors and attending physicians as they attempt to find a position elsewhere. If you are able to transfer to another program, will you lose a year or more? Have to start from scratch? Be forced into another specialty just to take a position somewhere in order to become board certified in something and employable in the future? Some who have been forced out of residency are unable to match into anything else and are unable to become board certified in any field whatsoever. There is not much out in the job market these days for General Practitioners. If you stay and “win” an appeal or litigation, what kind of work environment will you face every day for the remaining years of your residency? Your reputation is tarnished whether you fight or don’t. Is it worth litigation to attempt to preempt an unjustified termination? Is it better to just run while you can? Can you negotiate a resignation with a positive letter of recommendation from the program?
This complex situation makes physician residents a vulnerable population and helps explain why systemic challenge and change are so rare. It also explains why bad actors and harmful personalities can remain entrenched in their power positions indefinitely. They are hiding and protected in an environment that has been too slow to change and too resistant in expelling them. Even if challenged with litigation, what often seems to happen is that some sort of negotiated resignation is arranged by the institution in exchange for the resident signing a Non-Disclosure Agreement (NDA), such that other residents never find out how common these types of events are, and no good precedent gets created that could benefit others in similar situations. The secrecy is perpetuated. For all of Medicine’s technologic and intellectual advancements, some of its training environments remain in a primitive state.
From our own experiences and from conversations with dozens of residents across the country, the number affected by these issues is not small. If you have responsibilities that you have not met, then make the changes and efforts to meet them. In most instances, residency programs will (and must) work with you towards your development and improvement. That is their mandate. Both sides bear responsibilities. However, if your program is in violation of required processes, procedures and learning/working environment duties; if your program is failing you and your colleagues; if your program is doing you actual harm, do not accept it. Stepping forward (even if anonymously) and joining your voice with others will be instrumental in gaining attention and fomenting change in the systems upon which so many depend for well-being, education, and livelihood. Remaining silent can only purchase you persistence of the dysfunctions of the status quo – not only for yourself, but for your colleagues and for those that follow after you. The time has come to drive compliance, transparency and change. We believe that we are helping to force open a window for action and that the time to act is now. If not now, when? What does your conscience tell you to do?
Need a little food for thought?
And maybe a helping hand?
“The question isn’t ‘who’s going to let me; it’s who is going to stop me?'” —Ayn Rand
“There is no such thing as a dysfunctional organization, because every organization is perfectly aligned to achieve the results it currently gets.” — Ron Heifetz and Marty Linsky, The Practice of Adaptive Leadership.
“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.” —John Quincy Adams
“Real courage is when you know you’re licked before you begin, but you begin anyway and see it through no matter what.” —Harper Lee
“I am not a product of my circumstances. I am a product of my decisions.” —Stephen Covey
“Strength does not come from winning. Your struggles develop your strengths. When you go through hardships and decide not to surrender, that is strength.” — Mahatma Gandhi
“It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” — Charles Darwin
“Those who say it can not be done, should not interrupt those doing it.” — Chinese proverb
“People inspire you or they drain you – pick them wisely.”— Hans F. Hansen
“There are two primary choices in life: to accept conditions as they exist, or accept the responsibility for changing them.” — Denis Waitley
“The five stages of bureaucratic grieving are: denial, anger, committee meetings, scapegoating, and cover-up.” ― Charles Stross,
“Bureaucracy destroys initiative. There is little that bureaucrats hate more than innovation, especially innovation that produces better results than the old routines. Improvements always make those at the top of the heap look inept. Who enjoys appearing inept?” ― Frank Herbert,
“In any bureaucracy, the people devoted to the benefit of the bureaucracy itself always get in control, and those dedicated to the goals the bureaucracy is supposed to accomplish have less and less influence, and sometimes are eliminated entirely. [Pournelle’s Law of Bureaucracy]” ― Jerry Pournelle
Our Programs. Our Future. Our Responsibility.
GMECP: Driving education, awareness, and positive change towards systemic improvement for our programs’ residents, faculty, and staff.
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