I will always remember my awkward medical school interviews. Filled with bioethical scenarios and questions to measure my ability to prevent an impaired physician from practicing, the interviewers seemed hardly interested in my prior career achievements or humble beginnings.
Such discussions carried on through the first two years of medical school. They never taught us how health care reimbursement works or why different specialties pay differently, but there were plenty of lectures on how to protect your medical license if you fall victim to drug abuse and why you shouldn’t have inappropriate relationships with your patients.
It is indeed the charge of the powers that regulate medical education to repeatedly instill the tenets of professionalism within us, and I always wondered why, as I had thought this would be common sense for someone smart and capable enough to emerge as a practicing doctor. Having had other jobs prior to medical school, it just seemed like the aftermath of years of high profile sexual harassment and workplace whistleblower lawsuits should have corrected problems that you hear about being commonplace in another era.
Common to the medical education experience is the National Resident Matching Program (NRMP), also known as “the match,” a computer algorithm that uses the preferences of the medical student applicants to the preferences of the residency programs to simultaneously place all graduating medical students in training programs. I was pretty comfortable with my match at the time, as it afforded me the opportunity to learn my specialty in what is known as a community program, namely a group of private practice physicians which opts to train medical residents in exchange for government funding routed through its hospital training site. The smaller, closer-knit environment seemed to be a good fit for me. My plan was pretty simple — if I did a good enough job, I could make a home in this new place and hopefully become a clinical instructor there one day myself.
It did not take long for my excitement to wane. Within only a few days of starting my residency, I was called “retarded” and referred to with homophobic slurs. Women were commonly referred to with misogynistic labels. I was given no organized instruction on how to perform my duties, only criticized because I didn’t do things as the supervisor I’d had the prior day had taught me. My first month of residency was the worst experience of my entire adult education. I think anyone who has borne witness to television shows that depict medical education can appreciate that doctors can be hard on you as a trainee, but the extent at which personal attacks were levied at myself and other professionals is something that I didn’t anticipate and never came close to witnessing as a medical student. I was assured that this happens everywhere, but to this day, I refuse to accept that standard. I need to know that I made the right career choice.
My training program was guilty of many of the issues that other programs experience: fudging of duty hours (which are capped for trainees), an occasional unreported medical error, protecting other doctors in the face of patient harm, etc. But I was also subject to bizarre events like doctors running resuscitation codes who were not properly certified, patients being admitted to the hospital without an attending physician ever seeing the patient or signing the chart, and physicians who showed clear signs of dementia serving as the only supervisor of a new trainee. I did raise concerns about this to my program administrators, but I was laughed at and told that I was causing problems. I went outside the program and was met with a similar cold shoulder. It was a modern day reenactment of the movie Serpico; only there will never be any vindication for the main character in my tale.
After one semester of training, I was told that I had not been studying enough because I didn’t do well on the national in-service examination, a test given nationally used to measure your performance versus residents at other programs. I was threatened with academic probation and warned that I needed to read more, only I was never given any guidance on what to read or how to learn. These were private practice doctors with no ability or desire to teach. It was expected that we would learn on our own, and if we were good enough at figuring out how to practice medicine on our own, then we could join them and become millionaires of similar standing at the end of residency.
To make matters worse, residents ahead of me were starting to fail their board examinations, and nothing was being done to further education because the program director had carte blanche over decision-making. Rather than teaching us, it seemed obvious to me that these community doctors were just using us as labor. This is in contrast to what you would see at a larger academic medical center in which physician profit is more likely to be shared communally with lower paid specialists in the name of education. At my program, as the residents worked harder, the supervising doctors just took more vacations.
Late in my first year, I reached out to other programs where openings had emerged in hope of a transfer, but it was of no use. The NRMP, a computer algorithm sharp enough to garner its developer a Nobel Prize, also results in a nearly irreversible conclusion. With residents and programs matched so precisely, a resident who wants to leave a program causes dominoes to fall in a chain of resulting openings and transfers, and a “deserting resident” is more likely to be seen as a liability than an asset. Now realizing that I was academically behind other residents in the country, my ability to sell myself to another program was severely compromised. I just had to wait it out. It’s just the nature of the medical training beast.
There came a time in which a patient of mine died as a result of a procedure I’d performed. I was told that I needed to lie to the risk managers and make it look like my supervising attending physician was in the room even though he was nowhere to be found, and while I personally didn’t do anything wrong, it would just look bad if I was unsupervised. It became clear that the people I was working for did not live in a world in which accountability existed. In fact, any problems that arose with other residents were entirely swept under the rug even in the setting of gross malpractice, and the residents’ opinions were dismissed as immature and unfounded. As new classes of residents arrived in the years to follow, complaints about personal harassment, poor supervision, substandard didactic education, and abuse persisted, and all of it was swept under the rug.
A casual reader might look at this and think, “Isn’t there someone you can report your concerns to? Don’t you think that this isn’t really a safe training environment?” You can blow the whistle, but there are a couple of roadblocks. First, complaining, especially at a small program, puts you at considerable risk of what I refer to as passive retaliation. What I mean is that they can simply keep you from ever getting a job. Second, while you can complain to the Accreditation Council of Graduate Medical Education, about the only thing they can do for you is have your program’s accreditation revoked in which case you are no longer graduating from an accredited program. So that becomes a losing situation for the resident as well. Ultimately, when your supervising doctors are not beholden to a teaching institution or a hospital that abides by a professional code, nobody is capable of holding them accountable for much of anything.
In my third year, I was contacted by a patient’s attorney regarding another resident’s lack of supervision and how the attorney’s client was harmed as a result of it. They wanted me to testify against my bosses. This was a crossroads for me, because I no longer understood what it meant to do the right thing. I became severely downtrodden, agitated, and discouraged. The person I wanted to marry left me. I lost out on fellowship offers for reasons unknown to me — maybe because they found out I was a troublemaker, maybe because I just wasn’t qualified — I will probably never know, but I never “clicked” with my supervising doctors as a result of my disgust for their lack of respect for the profession, so I was never comfortable in asking for a recommendation letter in any case.
Today I remain discouraged, jobless, and deeply regretful of the decision I made as a medical student to choose the residency program that I did. I try to remain hopeful that someone will give me a chance and renew my interest in practicing medicine the right way, but it is hard to remain optimistic.
My goal in writing is that as this year’s match day approaches, I plead with the newly graduating doctors out there to please do your homework. Do ask about board passage trends, do try to find out why questionable programs don’t always fill with applicants in the NRMP, and do not assume that an appropriate educational plan is being offered at a program simply because it is accredited. The ACGME and the NRMP publish listings of programs that are on notice, so avail yourself of these listings. Your residency program is a place where you will work very closely with what may amount to be only a small number of supervising doctors, and you only really get one chance to make the right decision.
In my case, there were red flags that I did not pay close enough attention to. During my interview, the residents gave very short and incomplete answers to my questions, and several of them seemed downright unhappy. I had just assumed that the faculty were part of a medical school which was never the case, and I failed to do any research with respect to the effect that program size might have on education. Don’t make the same mistakes that I did, and best of luck to all of the new docs out there.
The author is an anonymous physician.
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