How to navigate residency probation [PODCAST]

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“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.”

This anonymous physician resident shares his story and discusses his KevinMD article, “How to navigate residency probation.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have an anonymous physician resident, and he wrote the KevinMD article “How to navigate residency probation.” Welcome to the show.

Guest: Hi, thanks for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Guest: Yeah, absolutely. So to start off, I’m a U.S. medical graduate, and I was a resident in a surgical subspecialty at a competitive academic institution. I was having difficulty adjusting to the culture, workload, and expectations of residency, and after a few years, I was placed on a residency corrective action, or residency probation. During the probationary period, I searched for information in order to make an informed decision about what to do next, and about what the actual program was like for others, but there was actually just very little information available, and even less information that was actually helpful.

Ultimately, this probation forced me to reconsider my career path, and after some careful thought and feedback from mentors, I decided to switch specialties and was able to match into a different one. I really wanted to write something that could help others in a similar situation, and also just be an example of hope if things don’t go as planned.

Kevin Pho: Tell me what it was like at that first residency program, and maybe share some of the events that led to the probation.

Guest: Absolutely. I think we often talk about that gut feeling when it comes to choosing a residency program. And I have to admit that I was a little bit blinded to that. I thought, “This program looks great on paper, and it would put me in a very successful position afterwards.” And so I ranked it very highly and ultimately matched there. But from the very first day that I was there, I realized that I didn’t fit, that my values were very different from the values of the faculty and my co-residents. And that’s not to say that their values were wrong or my values were right. It’s just that they were different, and kind of in constant conflict.

And I think what this did was, honestly, it isolated me. I just felt like I would go to work, work hard, and come back home, and I never really felt like I was a part of the team or a part of the program. And so subsequently, this started kind of making its way into my work, where I would make errors in documentation, or maybe communication errors. And eventually these things started to add up. And that’s what ultimately became the driver for being on residency probation.

Kevin Pho: When you said that your values didn’t fit with those of the residency program, can you give us some examples of that?

Guest: Sure. So I’ll say that the program I was at is, or was, a very traditional residency program. Surgical specialties tend to be more traditional in regard to culture and hierarchy. Everyone was just operating under, I guess you could say, fear, trying to avoid being yelled at, versus actual patient care, which is not something that is unique, I think, to any residency program. But I think they really valued respect for authority, and they really valued efficiency, while some of my values were creativity and learning. And I felt at the end of the day, my job was to make the attendings’ and senior residents’ jobs easier, as opposed to me being taught.

And so for me, it was just something that some people thrived in, though. Like I said, some of my co-residents just thrived in that environment and did very well and are great people. But for me, I didn’t feel like I was getting that kind of personal learning attention that I had gotten in school. And so ultimately, it was a conflict of those values that just made the relationship not work.

Kevin Pho: What exactly does it mean to go on residency probation?

Guest: Yeah. So it’s actually a little bit of a process. The process formally starts with what’s called a performance improvement plan. Essentially what that is, is your program director takes you aside and says, “Here is the list of things,” the feedback people have given about things that either have gone wrong or things to work on. And so what you do is you come up with a plan to address these things, and it can vary significantly. Mine in particular was to have a resident and faculty mentor that I had to meet with regularly. I would have to journal and report back to the program director as well. And so really, at the end of the day, this performance improvement plan is supposed to make you change your behaviors without any kind of formal documentation.

So you undergo a period of time where you go through this, and then they have a residency competency committee, and they decide if each resident is allowed to move on to the next level based on ACGME milestones. And if you are deemed not to hit a certain level of those milestones, that’s when they put you on what’s known as a resident corrective action, or RCA, or residency probation. This has a lot of similarities to the performance improvement plan, but the main difference is that now everything is documented. All of a sudden, you start seeing paperwork that you have to sign. And basically what the paperwork says is, “You will complete these following things, and any breach of this can result in termination or non-renewal.”

Now, each RCA or residency probation is actually very different. The ACGME says that if there’s a resident who doesn’t meet the milestones, each program needs to develop a plan for them, but it really doesn’t comment more on what this plan looks like. This RCA may look different between institutions, or even between departments. And so a large part of it is dependent on what the program has in place.

I will say that the program that I was in tried really hard. I was doing everything from, obviously, journaling and mentorship, but also seeking therapy and communication specialist therapy. And they even make sure that you go see employee health, to make sure that you don’t commit suicide, and to talk about depression. And another thing about the RCA is that you may have some of your clinical privileges as a resident revoked. For example, you’re not allowed to make any independent clinical decisions, maybe, without a senior resident or faculty member, and then also maybe you’re not allowed to do, say, bedside procedures or something without somebody there as well.

Kevin Pho: As you were going through these steps, can you share some of the feelings and emotions you were going through?

Guest: Yeah, absolutely. Even just thinking about it is making me a little bit emotional, just thinking about what I had to go through. I think a big part of it was, it felt very isolating, in that it doesn’t matter what size your program is, word gets out. There’s a saying, “Don’t jump in the water when there’s blood in the water.” And I felt like a lot of my co-residents started isolating me, or basically not being as familiar or cordial with me. And I get it. And that was just very sad.

It was this combination, since you asked about emotions, of feeling sad, feeling angry, feeling isolated and alone. Desperate is a word, because you think, “What am I going to do if this doesn’t work out? What’s my next step? What are my options?” And you start to feel helpless in the situation. All of these emotions make it incredibly hard to practice clinically at the same time. So while you’re feeling all these things, you’re still having to take care of patients, and even then, you’re under a microscope. Everything you do and say is being documented or reported back to the program director, or in some form to the ACGME, or the GME program at your school. And so it’s incredibly hard to practice clinical medicine in general, much less with all of these things weighing on you.

Kevin Pho: So tell me what the endpoint of your probationary period was.

Guest: Yeah. So ultimately, my contract was not renewed. There are three possibilities that can happen with a contract. One of them is you get off the RCA, right? Another one is non-renewal, and then the other one is termination. My contract was not renewed because I broke one of the clauses in the contract, and so that was a violation of that contract, and so the contract was not renewed.

Kevin Pho: So if your contract is not renewed, what are your options?

Guest: It’s a great question, because you’re already kind of further down the stream in regard to your medical education. And so essentially, you have to ask yourself, “Is medicine for me? And if so, where do I go? What do I do?” This really forced me personally, and I think it forces a lot of people, to kind of put everything back on the table, but in this way, with more experience, as opposed to as a fresh med student. And you really have to evaluate what these options are with kind of a new perspective, more of an adult perspective.

I would say that the first question is, “Do you want to be in clinical medicine or not?” That is the question that you should ask yourself. And then if you say, “I still would like to practice, I still would like to do clinical medicine,” you have to think, “Well, in order to do that, I have to complete a residency program.” And so you have to think, “Do I want to stay in this field? Or should I try to go somewhere else, or try to do a different specialty? And if I do pick another specialty, what is that going to be?” And so you really have to do a lot of introspection, and you have to really think about what your values are and what the values are that you see in the profession.

And yeah, it’s definitely not an easy decision at all. And it’s scary. I mean, this is like a horror story for any physician to even hear. They actually are quite surprised that I came out in one piece and am talking about it with a smile. But I think your choices really will depend on what you as a person find out from yourself.

Kevin Pho: So I understand now you’re in another residency program. How difficult was it to find this new residency program after the situation you had with your last one?

Guest: I will say that it was difficult, but not as hard as I thought it was going to be. One of the reasons why is that my story, switching out of a surgical specialty, was actually a pretty common one. When I was interviewing, I actually met quite a few interviewers who had a similar story, albeit without the probation, where they came to a realization that the path that they were initially on wasn’t for them. So I’ll say that that helped a lot.

I would say that there were some instances, I’m sure. You can never know for sure, but I do think that being on residency probation did affect whether I got an interview somewhere or whether I was accepted somewhere. But ultimately, I think you have to be honest, and you have to be genuine. That’s what everyone wanted to know, and I just told them the truth. I told them that this was a situation in which I kept going because I just wasn’t somebody who wanted to quit, and I just didn’t think there were other options. But I’m thankful for the way the situation ended, that it forced me to reconsider, and I think I’m in a much better place. So I think that the most important thing is to be honest during these interviews, because that’s what people really want to see, and people can really tell when someone is disingenuous very quickly.

The other thing is to maintain your relationships at your program. It is not human instinct to be kind or compassionate to people that you feel have wronged you. But ultimately, you’re in a position where you need their help. The first thing that a program that’s interested in an applicant who may have gone through a situation like that, or who is at least switching specialties, is going to want to know is, “What does the program director from that previous program think about this?” And so it’s important that you maintain a healthy and good relationship with your previous program. Plus, you never know down the line what that relationship will mean.

There’s a quote from Maya Angelou that says that people forget what you say and how you act, but they never forget how you make them feel. And so it’s important to not harbor, or not be explicit about, the way that you feel, even though it’s completely natural. So I think that relationship that I had with my program moving forward was incredibly important.

Kevin Pho: We’re talking to an anonymous physician resident, and he wrote the KevinMD article “How to navigate residency probation.” Now, after you’ve had some time to reflect on your experience, what’s some advice that you can give to others who may be going through something similar?

Guest: You are not alone. There are many residents who are undergoing similar things, and this can feel incredibly isolating. And you are not alone, and there’s a community of people out there. And hopefully, this article and others can help you make a good decision about where you need to go next. As I mentioned before, retaining good relationships with your program is very important.

Personally, self-compassion and mindfulness are critical for getting through this process. Honestly, it’s very easy to feel depressed about the situation. So really just allow yourself to feel the way you feel, but also understand that this is temporary, and that on a larger scale, whatever decision you choose or whatever happens to you will be the correct one, and it will lead you on a path to become a better person in ways you would have never predicted. I was listening to a different podcast, and they had people talk about their best and worst situations, and most of the time, they were the same thing. It can feel like one of the worst situations of your life, but it also may lead to one of the best decisions you’ve ever made.

Kevin Pho: And my final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Guest: There are two things I really think of. One, if you are the person undergoing residency probation, really think about everything around you, and increase your awareness to help you make the best decision, because in making a decision on whether to stay, whether to go, whether to switch specialties, you really need to be observant of your environment and of what your inner dialogue is. And then, to other people who maybe have a co-resident who is going through this, please reach out to them and be a source of support, because, as I mentioned before, it can be incredibly isolating, and having that connection is incredibly important.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Guest: Thank you.

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