Anonymous Doctor

I found out this morning that two of my co-interns aren't being asked back for next year. And neither one even killed anybody.

I don't even know what the right terminology is for not being asked to come back. I guess you'd say they've been fired. It's a job, we get paid, they don't have the job anymore, so that means they're fired. But it's more than just being fired, because it's not like they can very easily find a replacement job-- residency programs, at least not *decent* residency programs, don't seem like they'd be terribly interested in picking up someone who's been dumped from another program, even if they somehow have an empty slot.

It's mostly shocking because no one really tells us that hospitals do this. Not that they necessarily shouldn't, but it's kind of a locked-in path. You go to medical school, you apply for residency, you match with a program, and the understanding is that you're in that program for x years (3 years for internal medicine, other fields vary) and then you're a licensed doctor. Can't be a doctor without completing a residency. The 4 years of medical school becomes pretty pointless without completing a residency. [Not entirely pointless-- there are consulting firms that hire MDs, there's public health work, pharma, etc-- but assuming someone goes to medical school to be a doctor, you're not a doctor without completing a residency.]

And it's not like they paint this as an up-or-out profession. I have friends at law firms who go in knowing that there's a pretty decent chance they're not going to last until they make partner, and will probably be long gone way before then. This is different. No one expects to be fired mid-residency. Unless you do something horrible, you're supposed to be able to get through. That's the expectation. They already had schedules for next year-- the whole system has to be rejiggered now, because the hospital scheduled them for rotations next year, and now they have to move everyone else's schedule around to fill in the gaps. Hospitals don't really have extra doctors. Someone has to be doing admissions in the ER, someone has to be covering every floor, it's not like they can get rid of two residents and then we'll just have no one covering the patients on the 12th floor in September. They either have to hire new people to replace them [from where?] or cut everyone else's elective time.

The mechanics of how this plays out are not that interesting, I know. It's more about everyone being shocked to hear that these two people were fired without warning (at least without any warning anyone has heard about). I'm not saying there aren't reasons-- I'm sure there are reasons-- but what makes it alarming is that it's not because of anything black and white-- neither of them made any individual decisions that caused someone great harm.

It's a continuum-- we're all somewhere on this continuum between "ready to be a doctor" and "still seriously lost" and I don't think any of us really know quite where we fall. Like I said last week, I've had mostly good evaluations, but not entirely. Another poor evaluation or two, and would I be on the chopping block? I don't think I'd be-- I have no reason to believe I'd be, and even my less-than-awesome evaluations haven't had any magic words like "shouldn't be trusted to see patients," or "lacks effective medical judgment." But it's hard to be completely blase about it, because the stakes are so high.

Kicked out of residency means not just the loss of the job and the paycheck but really the loss of professional future, without exaggeration. The hospital just told two people who've spent years and years and hundreds of thousands of dollars that unless they can make a miracle happen and find another program that will take them mid-stream, they won't be doctors.

Of course I'm neglecting to focus on the flipside... maybe they shouldn't be doctors.

Because as high as the stakes are for the residents, the stakes are higher for the patients. And as people who use medical services-- if I can ignore the specifics of this situation, that two people I know and like now don't know what the heck they're going to do with their lives-- it's a terrible system if hospitals are reluctant to fire residents who they don't think are on the road to being great doctors. The last thing a patient should want is to be at a hospital that doesn't want to fire its residents because it's too messy a situation. If a resident can't be trusted to do a competent job, it's a real problem if they're your doctor, and it's a real shame if they get to finish the program and the world ends up with a doctor who doesn't know what he's doing.

I could fairly easily make the argument that residency ought to have a huge dropoff rate, that the hospital ought to cut people all the time-- that residency is our first real test of whether we have the capacity to be doctors (being able to pass exams in medical school is a terrible proxy for whether we can practice medicine) and it's a terrible disservice to the profession and to the public if people can skate by without having to prove themselves truly capable.

But the fact is that that's not the system as it currently exists. Residents don't get fired, not often, or at least no one talks about it if they do. Which is why this is really quite a shock-- and whether it's influenced by budget considerations (two fewer residents = two fewer salaries to pay -- although I hope that wasn't the driving factor) or the two interns simply had issues no one seems to be aware of, I don't know-- and is making everyone very nervous.

And, yeah, the first line of my post sounds like a joke, but I wasn't kidding. If you'd asked me yesterday what someone needed to do to get kicked out of residency, I'd have said you'd have to kill someone. What that means for our medical system is something I'll leave to you to discuss in the comments... because I need a nap.