The journey to becoming a physician is generally a linear path. Sure — there are exceptions, but for the most part, you can accurately predict what you will be doing in the future. For example, when you are in high school, the next step is college, then medical school, residency, possibly a fellowship, and finally your first job. (That’s approximately 16-18 years of your life!)
But what happens when things don’t go on as planned? In the earlier stages of your educational career, it’s easier to transition to something different. But what about in the later ones? Unfortunately, this was the dilemma I found myself in.
I was a few years into my residency program and was placed on a resident corrective action program (RCA) or residency probation because I was not meeting the ACGME milestones according to the department’s clinical competency committee (CCC).
As you can imagine, this news was devastating. And I took it very personally. I was surprised because I had always been told and believed that it was difficult “to fire” a resident and that probation was reserved for blatant offenses such as showing up to work under the influence, missing multiple shifts or a significant event that led to patient harm.
However, most reasons for residency probation are far more subtle, making them more difficult to understand and navigate. But this article is not meant to determine if these decisions are fair. Rather, I wanted to focus on the options and possible outcomes for residents who find themselves in a similar situation.
In my own journey for answers, there was limited available information, and an even smaller portion of it was actually helpful. Most content on this subject consists of anecdotal stories posted on internet forums with comments ranging from insightful to cruel. I understand why the information is difficult to obtain. For starters, it’s not common. Most residents don’t have to undergo an RCA, but it is common enough that every program director and graduate medical education (GME) program is familiar with the process. The other is that it can be embarrassing and feel like a failure on an emotional and personal level.
In medicine, sometimes asking or seeking help can be perceived as a sign of weakness to our reputation. A probation or RCA can feel like a personal failure, therefore making it easier to conceal or deny the problem to avoid judgment from others. I felt that given the gravity of the situation, residency probation should be discussed more openly and objectively to help others looking for answers.
First, let’s start with how you got yourself in this position. Residency programs are credentialed by the American College of Graduate Medical Education (ACGME), which develops program requirements for all residencies and fellowships.
Part of residency program accreditation is that the program must evaluate and give feedback to residents. According to the ACGME guidelines, “The program must provide an objective performance evaluation based on the competencies and the specialty-specific milestones.”
These evaluations must be done by multiple evaluators and be reviewed by the CCC. Suppose the CCC does not feel you are meeting your milestones or progressing. In that case, the ACGME states, V.A.1.d.3, states the program must “develop plans for residents failing to progress, following institutional policies and procedures.”
This is where things start getting tricky. The ACGME has given each institution the flexibility to individually develop a plan of action that explains the differences in the available information.
This is why someone else’s experience may not be the same as yours or vice versa. However, despite their differences, many institutions share a similar protocol. The first intervention is a professional improvement plan (PIP) or something similar and your first red flag. It is a conversation with your program director about issues identified on your evaluations. The meeting is not on your official record, and the goal is to call attention to these issues and develop a way to evaluate and address them.
Sometimes, you can be assigned faculty or resident mentors to help guide you, and there is usually some method of monitoring your progress. Basically, it is meant to change your behavior without formal paperwork.
If you are still perceived as struggling after the PIP, then the next intervention is a residency corrective action (RCA) or probation. This is a formal corrective process where your actions become a “patient safety concern.” In this stage, you receive a formal contract that contains the reason(s) for your probation, required tasks to demonstrate progression and competency, and the final outcome, which can be either successfully completing the probation and moving to the next year, residency contract non-renewal at the end of the term, or immediate termination. I cannot stress enough that this is a contract, and the results will go in your permanent record. If you break any of the terms within the agreement, you are liable for non-renewal or termination.
The required tasks can vary but are likely to be more involved than the PIP. Additionally, some of the “optional” tasks in the PIP may now be required. Tasks include but are not limited to: journaling, required sessions with a faculty and/or resident mentor and regularly seeing a counselor.
Regarding patient care, you may have some privileges removed. For example, suspension of independent clinical decision making or not being allowed to perform bedside procedures without a senior resident or attending present. This is such a serious predicament that the GME at my institution makes all residents placed on an RCA immediately go to employee health to determine suicidal ideation and if they are mentally stable enough to return to work.
No matter how these plans are presented, you need to treat the situation as dire. The stakes are high given the amount of time and money it took to get into residency, to begin with, and the limited options available to medical school graduates who don’t successfully complete residency. Therefore, how to proceed is extremely important.
The first thing I recommend is doing some true self-reflection to understand if you should try to stay, leave the program, switch specialties, or leave clinical medicine entirely. I found it helps to answer some questions to improve an objective perspective on your situation. The important thing is: to be honest with yourself. Sometimes seeking the advice of family or friends outside of medicine may help. Below is a list of questions that may help your decision:
- Is your situation due to a lack of effort or something deeper?
- Are you struggling to keep up with your colleagues?
- Do you trust the people in your residency program?
- Why did you choose this specialty?
- Now that you have clinical experience, what do you like? What do you not like? Can you see yourself doing it in the future?
- Are you prepared to meet the requirements and make physical and emotional sacrifices to go through with the probation period?
- Try to envision beyond the outcome. If you successfully complete the RCA or go to another program or specialty, what would your life look like afterward? Would you be happy?
If you decide to stay and work through the RCA, I cannot stress the importance of formulating a backup plan in case your contract is terminated or not renewed.
The best case is when you realize how to correct these issues, change your mindset, work hard — and come off probation. The worst case is you put in all the same effort but are still forced to leave. From personal experience, I have not seen many residents placed on an RCA successfully get through and move on, so it is very important you have a plan in place.
Another thing to consider is battling a self-fulfilling prophecy and expectations. No matter the size of your residency program, gossip spreads quickly. Even if you try to keep the situation confidential, it will likely not stay that way.
In some respects, it may be advantageous as some individuals may offer unsolicited support or advice that can help. But you will now be working under the microscope in that every decision and action will be judged under strict scrutiny. Things that faculty members do not notice in the other residents they will pay attention to with you.
It is not fair, but it is the truth and a natural tendency of human nature. Understandably it is very difficult, if not impossible, to successfully work in these conditions. Practicing medicine requires the ability to make sound decisions based on processing and integrating information. This neural pathway is inhibited in the anxiety-driven fight or flight state that an RCA creates.
From personal experience, I scrutinized every decision and interaction during the probation but missed the larger, more important concepts.
This commentary is not meant to say that successful completion of an RCA is impossible, but it is important to know that no matter what anyone says or how it is painted, in this situation, the cards are stacked against you. The earlier you come to this realization, the more informed decisions you can make.
If you decide to leave for a different program or specialty, it is important to retain a good relationship with your program. Maya Angelou has a famous quote, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
To apply for a different position, prospective programs will want to see support from your current program and program director and understand why you were placed on probation.
Beyond just finding a new residency position, state medical boards ask about residency probation when applying for an independent medical license. This is not an easy task and requires considerable strength and emotional management. Demonstrating courtesy, respect and kindness to individuals that you feel have harmed you is not a natural instinct. In fact, it probably would feel good to tell them how you really feel. But after you do so, the fallout could be disastrous.
Instead, I recommend changing your focus from anger to a new opportunity. Be thankful you had the opportunity to experience what you don’t like because it will likely pay dividends in your future.
Feelings of anger, fear, desperation and hopelessness make it very easy to paint a pessimistic future when placed on an RCA. However, this is only temporary and is not the end of your story. (Actually, it’s probably the most interesting part!)
Understand that on a larger scale, whatever decision you choose will be the correct one and will lead you on a path to become a better person in ways you would not have predicted. Sometimes the worst situations in our lives can also lead to the best ones. Besides, the most interesting people never took a linear path.
The author is an anonymous physician.
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