A major Boston teaching hospital experienced first hand the difficulties that can be encountered when they sought to remove a second year Orthopedic resident from their program. There were several concerning incidents which lead to the decision to terminate this resident. On more than one occasion, the resident made the unilateral decision to change a patient’s treatment plan without even consulting the patient’s attending physician. In one instance, a treatment program was changed upon the resident’s inability to implement the attending physician’s orders. This resident also reporting physical findings on patients he never actually examined. In addition, the resident had problems with tardiness and continually failed to write patient progress notes.
The Executive Committee who voted to dismiss the resident from the program was subsequently called upon to substantiate its termination decision. Fortunately, this Committee was able to demonstrate specific examples illustrating that despite warning and opportunities to improve, the resident had failed to meet the standards set forth in the Hospital’s Medical Staff By-Laws for judging the competency of the residency staff. These standards require that the residents demonstrate current competencies in the specialty, an ability to work well with others, high professional ethics and a capacity to participate in safe, effective and compassionate patient care under supervision commensurate with his level of advancement and responsibility. Given the specific examples which raised concerns about the resident’s competency, the Committee was able to conclude that the termination decision of the Chief of the Orthopedic Service was not arbitrary and capricious.
An article recently published in JAMA discussed the need for the identification of residents experiencing problems and how to deal with performance issues. These issues are best dealt with by a standard review process with the residents and their supervisors. Attending physicians in teaching institutions are required to instruct resident staff and continually assess their professional development. The latter responsibility can be most challenging because the criteria that is typically used to judge performance allows for tremendous discretion. When the resident’s competency or integrity are at issue and there has been no reported patient harm, verbal and written evaluations are extremely important. In fact, the JAMA study of internal medicine residency programs found that “60% of residency program directors agreed that it was difficult to convince problems residents of their difficulties because of a lack of honest and accurate written evaluations from attending physicians.” Indeed, 82% of the program directors reported that direct observation in a clinical setting was the most frequent method by which problems residents were identified.
When performing an evaluation, sometimes the attending physicians are reluctant to forthrightly evaluate physicians who are still in training. When the issue of discipline is raised with a resident who has performance issues, residency program directors may faced with threats of litigation. According to the JAMA study, 49% of internal medicine residency program directors acknowledged threats of litigation as a result of their dealing with problem residents. In addition, fifteen percent of these program directors indicated that their interactions with problem residents resulted in actual lawsuits being filed. Attending physicians need to be mindful that of the fact that their assessments can carry tremendous consequences for the resident staff and therefore need to be based firmly on the resident’s course of conduct and exercise of medical judgment as opposed to just personal opinions.
The JAMA article concluded that supervising physicians need to have a standard of review process in place for the resident staff. The review should outline clearly what is expected of the resident staff and the criteria that will be used to judge them in all categories. Periodic reviews provide supervising physicians with the occasion to raise problems with the resident staff and the opportunity for improvement. In addition, it gives the supervising staff a record upon which to rely should further action be required. In the Boston case, the recording of the orthopedic residents performance issues gave the Chief of the program a well-founded basis for the removal of the resident by pointing to several incidents which called the resident’s clinical judgment and professional character into question.
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